Paying for Pediatric Home Health Care: How Families of Children With Medical Complexity Navigate Gaps in Coverage

Caring for children with medical complexity at home: An integrative review

PROBLEM

Despite reporting significant systemic barriers to providing care, burden among parental caregivers of children with medical complexity (CMC) is often attributed to stressors related to disease management. The relationship between parental caregiver burden and systemic barriers within the healthcare bureaucracy, as defined by Ray's Theory of Bureaucratic Caring (BCT), has not been explored. The purpose of this integrative review was to examine which elements of the bureaucratic healthcare system are contributing to burden among parental caregivers of CMC living at home.

ELIGIBILITY CRITERIA

Refereed research articles related to the experiences of parental caregivers of CMC living in the United States published after 2014.

SAMPLE

1967 articles were obtained on initial literature search. Using the PRISMA algorithm, ten articles published between 2018 and 2022 were ultimately selected for appraisal.

RESULTS

Parental caregiver burden was consistently attributed to barriers and gaps among social-cultural, physical, political, legal, economic, technological, and educational elements of the bureaucratic healthcare system.

CONCLUSIONS

Weaknesses across the bureaucratic elements of the healthcare system prevent CMC from consistently receiving necessary care which in turn, contribute to feelings of burden among their parental caregivers. Efforts to alleviate burden experienced by parental caregivers should focus on addressing gaps within the healthcare bureaucracy.

IMPLICATIONS

Nurses are well-positioned to address these gaps through clinical work, advocacy, and research. Future research should further examine the appropriateness of using BCT to better understand the implications of systems-level weaknesses on parental caregiver burden. Parental caregivers of CMC should be closely involved in this process.

Building clinician-parent partnerships to improve care for chronically critically Ill children: A pilot project

OBJECTIVE

Multicenter pilot to assess feasibility, acceptability, and educational value of videos for families and clinicians regarding unique inpatient challenges of pediatric chronic critical illness.

METHODS

Videos were developed for 3 hospitalization timepoints: 1) chronic critical illness diagnosis, 2) transfers, 3) discharge. Parents of hospitalized children, and interdisciplinary clinicians, were recruited to watch videos and complete surveys.

RESULTS

33 parents (16 English-speaking, 17 Spanish-speaking) and 34 clinicians participated. Enrollment was better for families than clinicians (78% vs. 43%). Video acceptability was high: families and clinicians endorsed verisimilitude of depicted hospitalization challenges for chronic critical illness. All families felt the videos would help other families, all clinicians felt they would help other clinicians. Families gained expectations for the hospital course, discovered resources for hospitalization challenges, and learned there are other families in similar situations. Clinicians learned to recognize chronic critical illness, and how families experience hospitalizations, transfers, and discharges.

CONCLUSION

Educational videos about pediatric chronic critical illness were overall feasible, acceptable, and educational for hospitalized families and clinicians.

PRACTICE IMPLICATIONS

Just-in-time hospital education about pediatric chronic critical illness is valuable to families and clinicians; next steps are to assess potential to reduce gaps in care of children with chronic critical illness.

Home Health Nursing Agencies' Services for Children With Medical Complexity: Parent and Nurse Perspectives

OBJECTIVE

Many children with medical complexity (CMC) require the services of home health nurses (HHNs). Home health agencies (HHAs) hire, train, and manage nurses. For children to flourish, families, nurses, and HHAs must establish successful working relationships. Our objective was to understand the perspectives of parents and nurses about HHAs.

METHODS

In Illinois (IL) from 2019 to 2022, HHNs for and parents of children with invasive mechanical ventilation were interviewed. In North Carolina (NC) from 2012 to 2013, parents of CMC were interviewed, and from 2013 to 2014 HHNs participated in focus groups. Each dataset was initially analyzed separately for main themes relating to HHAs. Using collaborative thematic analysis, we determined themes common across datasets.

RESULTS

In IL, 23 mothers, 12 fathers, and 20 nurses were interviewed. In NC, 19 mothers, 6 fathers, and 1 grandmother were interviewed; and 4 focus groups of 18 nurses were conducted. Four common themes were identified. 1) HHAs do not have a uniform process for hiring and assigning nurses to cases. 2) HHAs have marked variability in training offered to nurses. 3) Shift scheduling, notifications, and communications with the HHAs frustrate parents and nurses. 4) Nurses and parents have little allegiance to specific HHAs; they frequently change agencies or work with several simultaneously.

CONCLUSIONS

Parents and nurses perceive practices for hiring, training, and staffing as inconsistent, and experience communication challenges. HHA-level problems may contribute to issues with HHN retention and complicate the lives of the families of CMC. Further research about this critical health care sector is needed.

"Fitting the Pieces Together": The Experiences of Caregivers of Children With Medical Complexity

BACKGROUND AND OBJECTIVES

Families of children with medical complexity manage a multitude of care responsibilities that must be carefully coordinated alongside typical family roles and activities. Currently, little is known about this experience from the perspectives of caregivers; therefore, the purpose of this study was to explore the experience of caregiving for a child with medical complexity while identifying unmet medical and psychosocial needs.

METHODS

Nineteen caregivers were recruited from the pediatric complex care clinic at an academic medical center in the United States. Each participant completed an in-depth, narrative interview that was audio-recorded and transcribed; transcripts were analyzed using an inductive coding approach.

RESULTS

Participants described their caregiving experiences along 4 themes: (1) the many responsibilities of caregiving, (2) insufficient respite care and skilled support, (3) financial limitations and costs of care, and (4) challenges with mental health and wellbeing. Participants identified unmet needs in 6 dimensions: (1) transition stress, (2) communication across teams, (3) learning to be an advocate, (4) purposefully inclusive environments, (5) finding connections and community, and (6) the challenges of coronavirus disease 2019.

CONCLUSIONS

Caregivers of children with medical complexity identify a host of experiences and unmet needs that challenge the physical, emotional, and psychosocial wellbeing of themselves and their families. With more attention to the holistic experience of caregiving for this population, providers and teams can better anticipate needs and provide services and programs that enhance caregiver and family wellbeing simultaneously.

Palliative care for NICU survivors with chronic critical illness

The sickest of NICU survivors develop chronic critical illness (CCI). Most infants with CCI will leave the NICU using chronic medical technology and will experience repeated rehospitalizations. The unique issues for these NICU graduates- escalating chronic medical technologies, fractured post-NICU healthcare, gaps in home health services, and family strain-are common and predictable. This means that raising family and NICU team awareness of these issues, and putting plans in place to address them, should occur for every NICU infant with CCI. Pediatric palliative care is one resource that can be engaged within the NICU to support the child and family through NICU discharge and beyond. This review examines what is known about the unique needs of infants who leave the NICU with CCI and the role that NICU-initiated palliative care involvement can play for these patients, families, clinicians, and the health care system.

Paid Family Caregiving for Children With Medical Complexity

OBJECTIVES

We evaluated Colorado's paid family caregiver certified nursing assistant (CNA) program by assessing stakeholders' perceptions of the model's strengths and potential areas for improvement.

METHODS

A professional bilingual research assistant conducted key informant interviews of English- and Spanish-speaking certified nursing assistant (CNA) family caregivers (FCs), primary care providers, and pediatric home health administrators of children with medical complexity in the family caregiver CNA program. Interview questions focused on the program's benefits, drawbacks, and implications for the child and caregiver's quality of life. Transcripts were coded and analyzed, and themes summarizing program benefits and disadvantages were identified.

RESULTS

Semistructured interviews were completed by phone with 25 FCs, 10 home health administrators, and 10 primary care providers between September 2020 and June 2021. Overall, the program was highly valued and uniformly recommended for prospective families. Perceived benefits included: (1) fulfilling the desire to be a good parent, (2) providing stable and high-quality home health care, (3) benefitting the child's health and wellbeing, and (4) enhancing family financial stability. Perceived drawbacks included: (1) FCs experiencing mental and physical health burdens, (2) difficult access for some community members, (3) extraneous training requirements, and (4) low program visibility.

CONCLUSIONS

Given the perceived benefits of the family CNA program, the model may be considered for future dissemination to other communities. However, additional research and program improvements are needed to help make this a more equitable and sustainable home health care model for children with medical complexity.