As Mitzi Johnson carefully turned the pages of a silver-bound photo album, she stopped occasionally to point out her son's first Christmas and his first birthday, and to exclaim over his chubby cheeks.

In all of the photos, Mark and Mitzi Johnson wear the tired-but-happy expressions trademark of new parents.

In several, private duty nurses smile alongside them.

For more than nine years, nurses have shared much of the Johnsons' life, from holidays and house moves, to the birth of more children and the first days of school.

The family relies on private duty nurses to care for their eldest son, Logan, who was born with a serious birth-related neurological injury. But like many families of people who require 24-hour care, the Johnsons have found that the benefits are more than medical.

Having a regular rotation of nurses allows the Johnsons to work, run errands and spend time with their two other sons.

When asked about the role nurses play in his life, Mark Johnson paused for a bit.

"It's more like survival," he said.

For 20 years, nurses and nursing assistants with the private duty division of Carilion Home Care Services in Radford have visited homes throughout the region. There they provide not only respiratory care, tube feedings and home exercise programs for patients, but also a much needed break for their families.

"A lot of people have the old concept of private duty services, which is that we sit with elderly people," said Terry Tilley, division manager and interim director. "Although we still have that as part of our program, we do have a lot of other services we offer."

Tilley said she knows of a limited number of other home care organizations in the New River and Roanoke valleys -- and fewer than 10 with contracts for Medicaid Personal Care. Carilion's division is one of the largest providers of private duty nursing in the region.

Over the years, the Carilion program has evolved from primarily custodial care to more skilled nursing services. A pediatric program was added 14 years ago.

Tilley said the division has expanded along with demand to meet more -- and more acute -- patients' needs.

Of the program's approximately 130 employees, Tilley said a majority are now registered nurses and licensed practical nurses. Many of the patients they serve rely on respirators, feeding tubes and other complicated medical equipment.

Bill Dombi, vice president for law with the National Association for Home Care & Hospice, said home care has become more widely known in recent years and is now recognized as a good, often cheaper, alternative to nursing homes.

According to an association report, the first home care agencies were established in the 1880s. The industry has grown steadily, accelerated by the development and expansion of Medicare and Medicaid in the 1960s and '70s.

Before nursing agencies offered in-home assistance for these patients, "either the family had to learn to take care of them or they were basically sent to nursing homes or institutions," Tilley said.

A soothing presence

For the Johnsons, neither of these options would have been possible.

Mark Johnson said he and Mitzi didn't consider staying at home because they needed to work and because Logan's complicated medical needs are best handled by nurses.

The 9-year-old is a paraplegic and relies on a ventilator.

The family also could not bear the thought of placing Logan in an institution, his father said.

"We had a nurse who rode in the car with us when we brought him home," Mark Johnson said. "We have had nurses the whole time because he needs someone 24 hours a day and, in order for us to have any life at all, it was obvious we couldn't do it all ourselves."

Paid for by the Virginia Birth-Related Neurological Injury Compensation Program, a total of six nurses now visit the Johnsons' Vinton home on various shifts.

One of the regulars is Mary Muse.

Muse, who has worked with Logan since 1998, knows the Johnsons so well she speaks of their home with "we's" and "our's."

The Troutville resident works four 12-hour shifts a week feeding Logan, checking his vital signs, giving him medications and taking him to doctor's appointments. Three days a week, Muse even goes to Herman L. Horn Elementary School with the fourth-grader.

Her regular presence is soothing to both Logan and his parents.

"I think it gives them some sense of security," Muse said. "They can go out without the worry of his care."

As a result, Mark Johnson works 40 to 50 hours a week for Aramark and Mitzi Johnson puts in eight-hour shifts at least five days a week at Desert Sun, the tanning salon she co-owns.

Outside help with Logan also ensures his brothers, Luke, 7, and Landon, 4, are not denied beach vacations or active sports schedules.

"You just have to forge on," Mark Johnson said of activities that take the family outside the home and away from Logan. "If we think about it, we don't do it. You start worrying about things that could happen."

Division expands

Carilion's private duty division now serves about 100 patients from two offices: one in Radford and one in Roanoke.

While the division's patients were once concentrated in the New River Valley, Tilley said employees now tend to patients as far away as Martinsville, Lynchburg and Tazewell.

According to the National Association for Home Care & Hospice, there are about 20,000 home care agencies, home care aide organizations and hospices nationwide. There are 7.6 million people that rely on their care.

Sheila McMackin, board president for the National Private Duty Association and founder of Wellspring Personal Care in Chicago, said the number of private duty care providers will likely grow as the country's population ages.

Like hospitals and nursing homes, however, some private duty home care organizations suffer from a shortage of nurses and nursing assistants.

"When you've got nurses going into homes, it's one-on-one care," Tilley explained. "It requires a lot more manpower and a lot more staffing to do that."

Plus, she said, state reimbursement levels make it difficult to compete with hospital pay rates.

On average, the division pays nurse aides $1 to $2 an hour less than hospitals. Registered nurses are paid $2 to $3 an hour less. Also, Tilley said, there is no extra pay for evening or night shifts in home care.

Despite the pay difference, some nurses and nurse aides say they prefer private duty nursing.

Muse, for example, used to work in an intensive care unit and doctor's offices.

"I love the continuity of care," she said of working with Logan. "I know what's going on with him; I can tell if something changes, assessment-wise ... it's great -- he's sort of like one of my own kids."

Brenda Brown, a private duty nurse for almost two years, has similar feelings.

"I really like working with the same patient," Brown said. "It's a very comfortable home to work in; it's a nice environment compared to a doctor's office, the pace, the stress."

Yet because of shortages, the private duty division has people waiting for services, including six or seven skilled nursing cases and 40 people waiting for custodial-type care under the Medicaid Personal Care program, Tilley said.

Most of the adults receiving care from the division do so through either the Medicaid Personal Care program or an Area Agency on Aging program. Most pediatric care is paid for by Medicaid waivers or the Virginia Birth-Related Neurological Injury Compensation Program.

Tilley said the cost of 24-hour care ranges from $300 to $350 a day for a nursing assistant to about $720 a day for a registered nurse.

'Making a difference'

Nursing assistant Ruby Harrison visits the Goad home in Draper eight hours a day, five days a week -- "as long as insurance covers it." And Carl Goad fully admits that he wouldn't last very long without her.

Even though Harrison comes to care for his wife, Goad said he relies on Harrison so he can get out of the house, run errands, stop by the Pulaski Senior Center and make thrice-weekly visits to the Pulaski Community Hospital for cardiac rehabilitation.

"It relieves you of stress," Goad said.

Dombi, with the National Association for Home Care & Hospice, recognizes the feeling.

"They need the break," he said of family members such as Goad. "Some of them have their other lives they manage, like going to work, but beyond that, these are respite opportunities."

And in some cases, Dombi added, these opportunities come at a lower price than a nursing home.

Often a family will rely on private duty care for just eight hours a day and provide the rest of the care themselves. At a nursing home, he noted, they would pay for 24-hour care.

Goad's wife, Juanita, has Parkinson's disease and is at a point where she can't do much on her own.

Harrison does everything from cleaning the Goad home to bathing, dressing, feeding and giving medicine to Juanita Goad.

"I appreciate it more than she knows, I believe," Juanita Goad said as she lay in bed.

Brown, who works with Christiansburg teenager Tiffany Penn, said helping family members, as well as her primary patient, makes her job all the more rewarding.

"Going to see the same family, the same patient, you can't help but get involved," Brown said, noting she had helped the Penn family pack and unpack boxes, run errands and even bathe the family dog.

"You do really know you're making a difference in the life of Tiffany and making a big impact on the health and welfare of the family," Brown added.

"And that's why you go into nursing -- to make a difference in the community, and that's what you do, one patient at a time."