‘Family CNA Model’ for Pediatric Home Health Patients Gaining Momentum Amid COVID-19

As states and cities shatter their old coronavirus records due to the current summer resurgence, health care officials and policymakers are once again shining a spotlight on high-risk populations, which include older adults in the community, individuals living in long-term care facilities and the immunocompromised.

One vulnerable group, however, is getting overlooked.

Between the worsening national nursing shortage and the COVID-19 crisis, medically fragile children — and the family caregivers who care for them — continue to receive little support. Pediatric home health providers are often enlisted to help, but even they are plagued by stagnant reimbursement rates and difficult workforce challenges, as in-home clinicians caring for medically fragile children typically make 20% to 50% less than their peers in other settings.


Team Select Home Care has experienced those challenges firsthand, according to Fred Johnson, the company’s president and CFO.

“Across our operations, we saw business decrease significantly early on, mostly due to a dip in new admits as well as an increase in missed visits,” Johnson told Home Health Care News. “On the pediatric side, the impact of COVID-19 hasn’t been as acute, but it has still hit us in a few main ways.”

Generally, those ways include a low-wage workforce opting not to work for safety reasons and parents of medically fragile children refusing visits from “strangers,” even in-home care nurses and certified nursing assistants (CNAs).

“We’re working with such a vulnerable patient population,” Johnson said. “And a high percentage of these kids are already on ventilators to begin with.”

Headquartered in Phoenix, Arizona, Team Select Home Care is a growing home health company that has nearly two dozen locations across eight states.

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While roughly one-quarter of Team Select Home Care’s overall business is tied to Medicare-reimbursed home health care services, it overwhelmingly operates in the pediatric long-term care and private-duty nursing spaces.

Founded over 12 years ago, Team Select Home Care started out doing predominantly Medicare-certified home health care. But it added to its business model about six years ago, establishing its robust pediatric long-term care service line, despite well-known workforce and reimbursement challenges.

It did so, in part, because of the long-term relationships and census stability that the pediatric home health care business provides.

“In the pediatric space, it’s generally a much lower margin business, but it’s typically long-term in nature when you’re talking medically fragile children,” Johnson said. “A lot of these kids don’t really have a prognosis to get better. What we can do is keep them comfortable and give them great quality of life by delivering good care in the home so they’re not living out their days in and out of hospitals, skilled nursing facilities (SNFs) and other centers of care.”

Workforce challenges

Team Select Home Care is far from the only big home health provider that works with medically fragile children. Moorestown, New Jersey-based Bayada Home Health Care has also built a substantial pediatric services line, as has Columbia, Maryland-based Maxim Healthcare Services.

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All of those providers have had to navigate a lackluster reimbursement landscape for years.

Pediatric long-term care services are often paid for by state Medicaid programs, which continue to squeeze providers with rates that fall behind general inflation and rising wages. To exacerbate matters further, just 2% of Medicaid spending for children with medical complexity has actually gone to home health care, according to one Health Affairs study.

“Medicaid reimbursement rates across most of the states haven’t increased much from 1980 until now,” Johnson said. “But as you know, nursing salaries, especially in the past few years, are skyrocketing as demand greatly exceeds supply.”

In order to staff a case for a medically fragile child and stay in business, companies like Team Select Home Care sometimes have to find nurses and other staff members willing to work for a fraction of what they could make elsewhere.

That’s nearly impossible to do when demand for registered nurses (RNs) is projected to grow 12% from 2018 to 2028, much faster than the average for all other occupations, according to the U.S. Bureau of Labor Statistics (BLS). The job demand for licensed practical nurses (LPNs) is projected to grow by 11% over that same period.

“In the pediatric space, depending on acuity, the vast majority of these children are cared for by LPNs,” Johnson noted.

The Family CNA Model

Although operating in the long-term pediatric care space still has its challenges, Team Select Home Care and other providers have found success in Colorado thanks to an innovative program that’s gaining traction nationally.

Under Colorado’s “Family CNA Model,” Team Select Home Care and its competitors are able to train parents or family members of medically fragile children to become certified nursing assistants (CNAs). If those prospective CNAs pass their tests, screenings and other requirements, the in-home care providers backing them can hire them as regular employees.

While LPNs are still used, CNAs can then take over some or all hours in lower-acuity cases. That allows LPNs to practice at the top of their licenses — and helps providers cut costs by utilizing CNAs, who are paid less than LPNs.

The parents and family members that are trained and hired as CNAs not only get paid for taking on the cases of their sons, daughters, nieces and nephews; they also add to a workforce that helps care for other pediatric patients across Colorado.

Providers win because they find dedicated employees who are passionate about their jobs in a competitive labor market. Colorado wins, too, because it saves money in the long run.

“The state wins by doing this because they can pay us anywhere between 30% to 50% less per hour for us to staff a CNA compared to an LPN or RN,” Johnson said. “Any state that implements this program is going to see a significant savings on every dollar and every hour worked.”

Medically fragile children also win.

Nationally, the 30-day re-hospitalization rate for pediatric nursing patients is estimated to be around 18%. Team Select Home Care’s 30-day re-hospitalization rate across over 700 patients in Colorado is only 3%.

To help train CNAs, Team Select Home Care actually owns and operates two training schools in Colorado. In all instances, the provider offers training free of charge with “no strings attached,” Johnson said.

“If parents don’t pass exams or move, … we just write that cost off,” he said.

Gaining momentum

Colorado’s program launched about a decade ago when a CNA — and the mother of a medically fragile child — advocated for such a model. Today, dozens of home health companies participate in it.

On its end, Team Select Home Care has hundreds of employees in the program.

Overall, employment of nursing assistants and orderlies is projected to grow 9% from 2018 to 2028, according to BLS statistics.

Regardless of the advantages, the CNA-training program in Colorado currently can’t be used in every state, as some state governments have restrictions on paying parents for taking care of their own children.

“Every state has its own ability to enact or not enact a program like this,” Johnson said. “A lot of states over the years have actually, for one reason or another, implemented regulations or policies that state parents cannot be paid for any kind of caregiving or care for children that they live in the same home with.”

Yet that appears to be changing due to a growing need.

Although less than 1% of children are identified as medically complex, the increasing population accounts for a disproportionate amount of health care resources.

Since HHCN interviewed Johnson, at least one state — Missouri — has decided to test out the Family CNA Model.

In June, Missouri’s governor signed off on an 18-month pilot program of the Family CNA model with 100 patients, exclusive to Team Select Home Care. To gauge results Johnson’s company will feed Missouri policymakers monthly data on cost savings, hospitalization reductions and more.

Johnson hopes the news in Missouri will trigger a “domino effect” and raise awareness of the model across the U.S.

“We support this type of solution because it drives significant cost reductions — and that’s so important at a time when states desperately need support due to their revenue shortfalls from COVID-19,” he said. “National attention is really needed at this point.”