Pediatric home care: A growing niche market with viability
Pediatric home care: A growing niche market with viability
This specialty market is proving fruitful for home care
In an increasingly home care-unfriendly world, a growing number of agencies are turning to niche markets in order to survive. For some, this means infusion therapy. For others, it’s cardiac care. The up-and-coming area of pediatric home care, untested in many areas of the country, also is proving to be a viable business market.
A look at this specialty shows that while the potential for growing a successful pediatric home care agency exists, it is not without its challenges.
The factors at play
Several issues play into the growing need for in-home pediatric services, not the least of which are the increasing survival rates for younger and younger premature babies. Infants born weighing as little as 1 pound now can be expected to survive. But not too long ago, the odds were certainly against them reaching their first birthday, let alone adulthood. These premature infants will, in all likelihood, need some degree of extra care, whether it’s in the neonatal intensive care ward or, as they gain strength, in the home.
Dorothy Page, MSN, FNP, is the home care coordinator for the University of Massachusetts Medical Center’s department of pediatrics in Worcester, as well as the co-founder and president of the National Association of Pediatric Home and Community Care. With more premature infants surviving, she says, "There are a whole host of things that can result. The most complex will need feeding tubes and life support, but there are others with cerebral palsy who need physical or occupational therapy. Many would have stayed in intensive care units for months and even up to years. But now with cost containment, as soon as the child is stable, the child is sent home."
It’s not just preemies who have created an additional need for home care. New treatments for children with cancer and cystic fibrosis have contributed as well, she says. "They may be receiving chest therapies, respiratory and feeding therapies while they’re at home to help them either get over the hurdle of an acute [condition] or cope with a chronic illness. As they find more therapies to help children with chronic disease, more children will be needing home care."
Science has done its part to increase the number of children eligible for home care, but perhaps nothing has had so great an effect as the involvement of parents. "Families want the children home," Page explains. "They don’t want them in an institution. It’s so important for the family’s sense of being an intact unit. Parents really have demanded that their children not live in the hospital for any length of time, and with the advent of payer systems that look at home care as a cost-effective alternative to hospitals, demand and need meet."
The prognosis for pediatric home care agencies remains strong. The pediatric home care unit of Children’s Hospital of Denver has more business than it can handle, says Linda Therrien, RN, MSN, director of home care and community health programs, and the pediatric representative for the National Association for Home Care (NAHC) in Washington, DC.
Still, it’s doubtful the rapid-fire market growth will continue exponentially. Page says that while the market will continue to grow, "The huge balloon of numbers that we have seen will increase, but much more slowly," partly because some therapies are producing quick results, lessening the amount of home care a child needs.
All things considered
The pediatric home care market is growing, but some homework is still necessary. Before jumping into the market, take time to do some background research, advises Page.
"Agencies interested in starting a pediatric program should go out and talk with other agencies locally to learn about the pitfalls and rewards," she says, adding that since reimbursement is determined on a state-by-state basis, a local pediatric agency is the best bet for learning about reimbursement policies and problems.
If, after talking with other agencies, you’re still interested, look at your own agency’s referral history, says Nancy Lord, RN, BSN, MBA, CCRN, director of home care for Voorhees (NJ) Pediatric Facility Home Care: "If you are turning down many, many pediatric cases, then you’re not hitting the right niche. But if that area or subspecialty is covered by other agencies, then it’s a losing proposition. If you’re not turning down cases left and right, you’d have to put out a lot of money before you’ll see a return."
Freestanding agencies may want to investigate the option of partnering with an area hospital, says Therrien, who encourages new entrants to the pediatric field to make sure their services complement, not compete, those of other area providers.
"A lot of hospitals are beginning to question whether it makes sense to have their own agency or simply a referral agency where they could trust the quality of pediatric services," she says. "If you’re in a community with a children’s hospital, the first thing to do is check to see if they have a home care agency or if they would be interested in developing a relationship with you to provide it."
Even if your particular area shows a need for home care, the issue of reimbursement must be considered. As with Medicare, Medicaid reimbursement can be tricky. "There’s no consistency for what Medicaid will pay and how much, so it’s extremely difficult for families with special-needs children and for agencies," Therrien says.
Third-party providers do pay, but rarely. Even then, they cover only the bare bones. Of 21 children billed under private-duty nursing, she explains, three have private insurance companies and then they pay only a portion of reimbursement.
"A closed HMO system is less inclined to pay for chronic home care for kids, and unfortunately that’s what they need if they’re premature and have related problems or if they’ve had an accident with trauma to the neuromuscular system. They’ll be dependent on technology and will need skilled services for at least two to six years or even a lifetime. Kaiser might pay for three days of nursing care to get a child with a new [tracheotomy] out of the hospital. So in theory, we would have three days to get mom confident with it," Therrien adds.
Page says she has found that Medicaid, "if we give them all the documentation as to why the child needs home care . . . tends to listen and approve the nursing hours."
The challenges of children
If you think pediatric home care is just like home care for adults but with smaller patients, you’re wrong. "The biggest challenge for agencies is to realize that patients are not small adults and as such you need specially trained people, and not just those that are familiar with pediatrics in general," says Lord. "With adults, you can reason with them, while with children you need to establish a rapport and make therapy a game — something fun and interesting so they’ll be willing to participate. Otherwise, they’re just going through the motions."
Page agrees. "To say a nurse who has worked with adults and who has several children at home could care for an ill child at home is not a logical transition. They need training to deal with the issues of the child and family. They need to remember that they’re working within the family system and that with a child, you are looking to maximize their outcome for life."
The agency itself faces several challenges, including equipment and services management. For instance, you can’t use an adult infusion company, Therrien points out, because the formulas and calculations are different for children and the drugs interact differently in them. Some agencies advocate a full range of services, offering respiratory and physical therapy, infusion services, and nutritionists, to name a few.
Equipment, too, can pose a problem. Not only is pediatric equipment different from that used for adults and requires special training to use, but children require a spectrum of sizes as they grow. The adult, notes Lord, will use a walker until it wears out or breaks. But for children, "you will need to make adjustments and buy new ones as they grow. It is very challenging for home care because you’re constantly having to reorder," she says.
Can you find qualified staff?
There is also the challenge of finding a highly skilled staff of pediatric nurses. Recent graduates don’t have the same experience with pediatrics, Page says, noting that they have spent only a few days, not a semester, caring for children. To counterbalance this, she believes agencies should set up a comprehensive training program.
For agencies branching into pediatric home care, the lack of highly skilled staff could be a stumbling block. One way around this is to start out slowly, perhaps with skilled visits. "As your knowledge base increases along with the number of nurses, you can move to block nursing where you send nurses to patients for blocks of time," Page suggests.
Therrien’s agency requires nurses with two years of experience and "even then we screen them very carefully." She also has potential hires accompany a nurse on visits so they have a sense of what they’re getting into.
Agencies also need to know their limits and inform parents of them, starting with the fact that the nurse is not a baby sitter for the other children. "The agency needs to have a clear understanding of what it intends to provide and stick to it. It can’t overstretch the limits because then the family tries to cover the nursing duties and the child only ends up sicker because the family is stressed," Page points out. "Nurses have their limits to what they can do. In one case, a mother asked one of my nurses to look after the other children while she ran out to the store. The nurse needs to say, No, I can only look after this child.’ They need to be able to prepare the family for the likelihood that if nursing services stop, they will have to care for the child on their own."
In reality, the pediatric home care worker is as much nurse as social worker. "You need someone who is a critical thinker, who can work independently but who knows when she needs to call for help. It’s difficult for nurses because they practice really in isolation. She might leave the house in the morning, go straight to her patient, and then return home at night without ever coming into contact with other nurses," Page explains. "There is the added challenge of coping with the idea of rules in the workplace vs. those of the family and home. Can you tell the dad, No. You can’t walk around in your house in just a towel’?"
Despite the challenges, pediatric home care is extremely rewarding, these sources say. And things are looking up for reimbursement, says Therrien.
"When for-profit proprietary agencies went in to managed care contracts, that cut us to the bone. We had to try and compete with their prices. But now the for-profits have found out they can’t survive on that low reimbursement either. We’ve had third-party providers come to us and say they wanted to improve our rates. So really, what goes around comes around. It’s just rare you get a chance to see it in your lifetime," she adds.
Sources
• Nancy Lord, RN, BSN, MBA, CCRN, Director of Home Care, Voorhees Pediatric Facility Home Care, 1304 Laurel Oak Road, Voorhees, NJ 08043. Telephone: (609) 346-3300.
• Dorothy Page, MSN, FNP, Home Care Coordinator, University of Massachusetts Medical Center, Department of Pediatrics, 55 Lake Ave. N., Worcester, MA 01655. Telephone: (508) 856-4155.
• Linda Therrien, RN, MSN, Director, Children’s Hospital of Denver Home Care, 1056 E. 19th Ave., Box 215, Denver, CO 80218. Telephone: (303) 573-1234.
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