CHAPEL HILL - Soaring gas prices are driving some of North Carolina's visiting nurses off the road. Others are refusing to take on new patients. The trend, service providers warn, could increase health care costs and force critically ill patients to leave home.

Naisha David, a nurse's aide at Good Health Services in Raleigh, said she no longer accepts cases in Cary, Fuquay-Varina or Apex.

"Gas is just so high that you can't afford to travel the distance, even though we may love what we do," she said.

Sandi Massey, vice president of clinical services at Good Health Services, said her agency has lost employees to gas prices, especially at the agency's Kenansville office in rural Duplin County.

"I've had people look at going to the hospital where they can actually stay for an eight-hour shift," she said.

Home health workers and companions help patients remain independent, living at home instead of in costly retirement facilities or nursing homes.

Betty Klauber of Chapel Hill applied for companion services from the Chapel Hill-based A Helping Hand last spring after her husband, Sam, grew too frail to be left alone while she ran errands. She hopes her husband, who is 99, can stay at home for the rest of his life, and said the service is helping him do that.

"It's just been a godsend for me," she said.

But in interviews, directors of home health care agencies and trade groups warned that if the industry continues to lose workers, more patients -- particularly those in rural areas -- will end up in nursing facilities, driving up health care costs.

"We're really going to have a problem," said Amanda Thomas, director of research at the National Association for Home Care and Hospice. "It could be a huge trickle-down effect."

The statewide average price of gas this week is $4.02 a gallon, up from $2.85 just a year ago, according to www.northcarolinagasprices.com. Nurse's aides, who do the bulk of home visits under the state Medicaid home care program, typically earn between $9 and $10 an hour.

Christine Mair, a companion to elderly people and graduate student, drives hundreds of miles every week taking clients to lunch, to doctor visits and shopping.

Mair's agency, the nonprofit A Helping Hand, provides companion services to 400 people each year in Orange, Durham, Chatham and Wake counties. It reimburses workers for driving clients on errands but not for travel to clients' homes. Mair drives a fuel-efficient car with manual transmission, but she still pays up to $50 a week for gas to travel between her Raleigh home and clients in Pittsboro and Chapel Hill.

"It gets pricey," she said.

Billions of miles

Across the nation, home health care workers drove nearly 5 billion miles to reach patients in 2006, according to a study released at the end of June by the National Association for Home Care and Hospice. In North Carolina, which ranked fifth in the nation for the number of miles traveled, workers made more than 15 million visits to homebound patients.

Thomas said that about half the home health-care agencies she surveyed reimburse their workers for mileage at the IRS rate, a standard figure used to determine reimbursement amounts but that others do not pay for mileage at all. The IRS recently increased mileage rates to 58.5 cents per mile.

Some relief could come in a Medicare package now before the Senate. The association is lobbying lawmakers to restore a provision that would increase certain payments to rural health agencies by 5 percent to help cover transportation costs. Previous Medicare packages included the extra payment, but the provision expired in 2006.

Scheduling changes

Managers of Triangle home health care and companion organizations said that they are reorganizing the way they schedule home visits but that, so far, patient care has not suffered.

"The difficulty lies with the staffing people in being more creative," said Margaret Rice, a clinical supervisor at At Home Quality Care in Raleigh. "Patient care has not been compromised."

Cathy Ahrendsen, executive director of A Helping Hand, said her agency is recruiting companions from outlying communities, closer to clients. And a student intern is using the mapping tool Google Earth to create the most efficient schedules, she said.

Darcy Dye, a spokeswoman for Hospice of Wake County, said her organization, too, has reorganized how it assigns visiting nurses. And a few of the organization's 200 volunteers have asked for clients closer to home.

But she said making worker travel more efficient has benefits.

"We've always been conscious of how we do our travel," she said. "We want to spend our time with our patients, not in the car."