Dr. El

The other day over lunch a colleague said to me, “Imagine how things would change if toileting were a billable service.” I laughed, briefly considered that fanciful notion and continued eating my meal. 

As I gave the idea further reflection, however, it might not be as laughable as it first appears. 

Consider the following:


Remuneration for toileting would mean that aides would hold income-generating positions. We’d expect that nursing departments would become fully staffed in order to take advantage of this new funding stream and that compensation for aides would increase.


We might also anticipate that CNAs would become more highly valued for their services by others in the facility. 

Philosophical shift

Direct payment for the tasks of aides would strengthen incentives for employers to support ways for employees to manage their jobs around their lives, which often entail demanding family caregiving responsibilities. 

Retention programs/employee benefits

The funds could be used to develop retention efforts such as flexible schedules, onsite daycare, financial contributions to staff education and other employee benefits. 


Increased remuneration for personal care would lead to more resources for training and for creating programs that promote the development of CNAs, such as peer mentorships. 

Greater staff stability

Teamwork flourishes with steady, informed, reliable workers — staff stability allows time for relationships to develop so that well-trained colleagues can do the work of an interdisciplinary team together. Residents and families are able to build relationships with knowledgeable, consistent employees. Nursing staff who know the residents are more able to detect subtle changes in behavior, cognition and physical condition which can allow for early treatment of problems.

Increased staffing

When a facility has enough staff members to meet the needs of residents, we would expect to see improved quality of care and fewer time-consuming family and resident complaints.

Improved toileting

The number of falls would decrease because residents wouldn’t be trying to get up in frustration to toilet themselves. (Anecdotally, I’d say this accounts for 50% of falls.)

We’d see less skin breakdown because people would be cleaned immediately. We might find fewer residents with catheters and reduced urinary tract infections and concomitant problems. 

From a psychological perspective, it can be very depressing to experience the loss of the ability to independently manage one’s own bodily functions, compounded by the need to rely on others who not only aren’t immediately available, but say things like, “Just go in your diaper. I’ll clean you later.” 

Residents worry about receiving timely care for themselves and become distressed on behalf of others who are left to soil themselves. Under the new payment system, elders who make frequent requests for toileting might become facility darlings, altering the dynamic in the day room.

With regular toileting, residents would feel less depressed and anxious, which could reduce the need for psychotropic medications. 


The more I considered the idea of funding for toileting care, the more the benefits became apparent. The only downside I could imagine was that instead of hearing residents complain about the waits they experience for personal care, I’d start hearing stories of residents being toileted too often. 

I’ll cross that bridge when I come to it.

Eleanor Feldman Barbera, Ph.D., author of The Savvy Resident’s Guide, is an Award of Excellence winner in the Blog Content category of the APEX Awards for Publication Excellence program. She also is a Bronze Medalist for Best Blog in the American Society of Business Publication Editors national competition andGold Medalist in the Blog-How To/Tips/Service category in their Midwest Regional competition. To contact her for speaking engagements and/or content writing, visit her award-winning website at MyBetterNursingHome.com.