Workforce, Reimbursement Challenges Creating Shortage of Pediatric Home Health Providers

Despite soaring demand, a dire lack of qualified caregivers and a complex patchwork of state-by-state payment mechanisms are contributing to a severe shortage of pediatric home health agencies operating in the U.S. market.

Providers typically focused on older adults may be positioned to tap into the pediatric opportunity, experts say, but only if they’re prepared for the long haul.

“There’s really a national shortage of home health care workers who have the skills to care for the level of needs [medically complex] children have,” Dr. Carolyn Foster, an assistant professor of pediatrics at Northwestern University’s Feinberg School of Medicine, told Home Health Care News.


Although there’s a clear need for more, a handful of providers have already shifted their focus to the pediatric home health front.

One example is Moorestown, New Jersey-based Bayada Home Health Care, which gets roughly one-third of its revenue from its pediatric home health services.

A second is Maxim Healthcare Services, which serves between 20,000 and 40,000 patients on any given day, the majority of whom are children. While the Columbia, Maryland-based company also maintains population health and staffing divisions, pediatric home health has been its bread and butter for more than a decade, Dr. John Langley, senior vice president and chief medical officer for Maxim, told HHCN.


“Over time, Maxim — as with every [home health] company — has developed its niche,” Langley said. “That’s where we focus much of our development and, frankly, many of our resources.”

Maxim is currently in the process of selling its home health care division to Aveanna Healthcare, yet another pediatric home health giant. Backed by Bain Capital Private Equity, Aveanna has more than 180 locations in nearly two dozen states.

A second tsunami

When it comes to the future of home-based care and macro-level forces shaping the industry, stakeholders often point to the “silver tsunami” — or the more than 10,000 baby boomers who turn 65 every day.

For the most part, the silver tsunami hasn’t come close to fully crashing. There is, however, a second wave that’s arguably already here, one comprised of medically complex children.

“What has happened is the acuity level of pediatric patients being discharged from hospitals has risen exponentially, especially as hospitals are struggling for space,” Langley said. “There has been an increase in the number of home care providers, but [keeping up] remains a constant challenge, as more and more critically ill patients are finding their way home.”

In general, pediatric home health patients are often children with extremely high health care needs who rely on specialized equipment for support. That may include a child born prematurely whose lungs aren’t fully developed, making the use of a ventilator necessary.

“A lot of those children end up running around like normal kids eventually, but there are several very critical years where they need that home ventilator to allow them to live at home,” Foster, who is also a physician at the Ann & Robert Lurie Children’s Hospital of Chicago, said. “And when you have that in place, you need a nurse.”

Pediatric home health challenges

Due to the medical complexity of patients — and the fact children are usually more difficult to care for than adults — finding qualified caregivers has been a major challenge for pediatric home health providers. That’s one of the reasons pediatric home health hasn’t been a more lucrative business thus far.

Finding qualified staff is further made difficult because funding often goes to hospital settings, leaving home health providers with fewer resources to pay their employees.

Overall, just 2% of Medicaid spending for children with medical complexity has gone to home health care, according to a recent study published in the journal Health Affairs. As a result, median hourly wages for pediatric home health care services in 2017 were $33.77, compared to an average of $36.45 for in-patient care.

“The biggest challenge facing pediatric home care is access to that care,” Langley said. “That access falls into a number of categories, perhaps the most important of which is reimbursement. But it’s certainly the availability of qualified nurses too — not just having a warm body.”

In part, Maxim has worked to recruit prospective home health staff by connecting nurses to mentors right out of college, he said. The company has also teamed up with the Johns Hopkins University School of Nursing to develop online training programs.

Meanwhile, federal policies have created a relatively steady reimbursement climate for long-term services and supports for older adults in the home.

In contrast, pediatric home health fundingrelies on a state-by-state patchwork, with some states having more favorable reimbursement landscapes than others.

At its core, that patchwork is largely made up of Medicaid funding, private pay and commercial insurance.

“Reimbursement varies from state to state,” Langley said. “It varies from Medicaid to MCOs, to private-pay and commercial insurance. Again, that is a state-by-state variation. We have had some states where reimbursement is reasonable. We have other states where it is very difficult for us to manage patients paid by Medicaid.”

In fact, Maxim has had to cease its private-duty nursing home care operations in South Carolina because reimbursement was so poor, he said.

Quality measures and moving forward

Unlike Medicare-certified home health care for older adults, there are no quality measures for pediatric care delivered in the home.

That’s a challenge for consumers, but also a roadblock to pediatric home health gaining access to possible value-based funding streams, according to Foster.

“There should be transparency for families, so they can pick the agency that’s the right fit for their child. I think benchmarking is good for consumers,” she said. “But it’s important for improvement too. If you have no way of benchmarking or measuring, it’s difficult to tell whether you’re [improving].”

To advance pediatric home health in the U.S., hospitals and health systems are opening lines of communication with home health partners, educating them about their needs for those types of services.

“Places like Lurie want to be a source of support for companies that are interested in providing care to our patients,” Foster said. “We offer CME opportunities for nursing staff so they can be trained to care for kids.”

Forming hospital relationships can sometimes be difficult for home health providers. Getting into the pediatric home health game may open that door.

“I think there’s a real disconnect right now — I don’t think we know who to go to and how to reach them,” Foster said.

Langley’s advice for more traditional home health providers interested in building a pediatric home health presence: Start now. Doing so isn’t easy — and it takes time.

“It would be very difficult to do that,” he said. “The regulations are just very difficult. Frankly, there are so many regulations that it becomes hard to keep abreast of them state to state. With Medicare and adult patients, it’s one set of rules.”

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