Kathy Vargulic (left) finds her day-care center complements the pediatric home care children receive.

Adeliz Vicens had misgivings about leaving her child at day care. So do most working parents. But most of them do not have babies born 4 month premature, with all the special needs that entails. Maybe tiny Alexa belonged at home, with one-on-one care, protected and isolated.

Many parents have qualms when they first consider day care for medically fragile children, says Kathy Vargulic, director of medical day treatment for Tender Health Care in Marietta, Ga. Although adult day care for seniors receiving home care is becoming more common, the concept of a pediatric version of such a facility is new to most parents—and to many third-party payors.

“A handful of other organizations are providing these services, but PSA is kind of leading the charge,” says Joseph D. Sansone, president and CEO of Tender Health Care’s parent company, Pediatric Services of America (PSA), Norcross, Ga. “The centers are still embryonic in concept to a lot of states and our task is to show their cost-effectiveness.”

PSA began providing the service in the late 1980s in Florida and later added three centers in Georgia. The Georgia centers deliver nursing, developmental therapies, and education to special-needs children from birth to 6 years of age. The five Florida centers serve children up to age 21.

Sansone hopes that by demonstrating how these centers can save payors money, PSA can expand the program to other states and thereby make home care for children more affordable and accessible.

However, selling the pediatric day care concept to both payors and parents is not easy. Some parents feel their children do not belong in centers like these, Vargulic explains. Most of the children at Tender Health Care were born 3 to 4 months premature, and many are on ventilators or have neurological disorders. Other children may have developmental disorders.

“Parents don’t always see the things we’re telling them, and sometimes they get angry,” Vargulic says. “I had a mom come into my office and cry because she didn’t see why her 3-year-old belonged here. She thought her child looked much better than the other children did. Mind you, her child had spinal bifida, we didn’t know if he would walk, and he had a tracheotomy and a gastrostomy tube. He ended up coming because she didn’t have anywhere else to put him. Now, he’s walking and talking and she is one of our biggest advocates.”

The opportunity to interact with other children is a major benefit of day-care for medically fragile children.

Children First
Walking into a day care center for medially fragile children for the first time can be disturbing for people unaccustomed to seeing children with serious medical problems, but Vargulic hopes most people see beyond that once their first impression wears off.

“[Entering the center] you would see a lot of equipment and tubing, but mostly you would see technology-dependent and fragile children being children,” she says. “You would see them painting, out on the playground—it would be very similar to being in a regular child care center.”

Each day, the Marietta center cares for between 45 and 60 patients, divided into classes according to chronological and developmental ages, Vargulic says. It maintains a three-to-one ratio of staff to patients to tend to the children’s physical needs, in addition to education professionals to help with their mental development.

“Our whole goal is to rehabilitate the children and to mainstream them into whatever kind of program works for them based on individual needs and disabilities,” Vargulic says.

Social Climbing
Children at Tender Health Care receive regular speech, physical, and occupational therapy. Patients also have an opportunity to interact with their peers, an important benefit children who spend the whole day at home may miss out on.

“PSA is a home health care company, so obviously I’m a huge proponent of home care,” Vargulic says, “But usually, once children are medically stable, they need to socialize and interact with other children. So the kids were being serviced for years in the home with one-on-one private-duty nursing, which was developmentally inappropriate. The families socially isolated these kids, thinking they were doing really good things for them, and that just increased their developmental delays. They were getting developmental therapy, but it was maybe once or twice a week.”

Tender Health Care bases its admissions on a child’s need for skilled nursing and developmental care and the potential for rehabilitation. Children without rehabilitation potential are not candidates.

Positive Outcomes
Having an established track record of good outcomes and cost savings has enabled Tender Health Care centers to find reimbursement that eluded them in the early days of their pediatric day care program, Vargulic explains.

“We track every single infection, hospitalization, and emergency department visit, so I could tell you that our preemies have fewer emergency department visits and fewer rehospitalizations than peers who are not in medical day care,” she says. “It is less costly, and they have better developmental outcomes. We are getting more and more insurance companies interested. Some companies hands-down approve it, others we manage on a case-by-case basis. A lot of the children are covered under Medicaid because almost all my kids were born under 1,500 grams.”

Tender Health Care’s status as a division of Pediatric Services of America gives Vargulic some leeway in considering cases where reimbursement might be less than optimal.

“PSA’s a national pediatric home care company, so we are able to provide for and meet all the medical needs of the child,” Vargulic says. This means that the company can consider many factors in deciding if taking on a particular day care patient makes sense from a business point of view.

For example, the company will sometimes do short-term private-duty nursing in the home for a future day care candidate so the family can learn to care for their child. Plus, PSA often provides the oxygen, monitors, ventilators, tracheostomy equipment, ostomy supplies, or other products the child needs. Finally, PSA’s pharmacy may provide drugs such as immune globulin for prevention of respiratory syncytial virus infection.

Vargulic foresees a growing need for care for medically fragile and technologically dependent children as premature births increase, which may bode well for the growth of day care centers for these children, as well as for companies that provide the health care equipment the children rely on. Although many Tender Health Care’s patients use PSA equipment, some use equipment from other providers.

“One in every nine births now is a preemie,” Vargulic says. “A very conservative approach would be 10% of those kids are going to need long-term services initially.”

Vargulic believes the day will come when no one will question the value of pediatric day care for medically fragile children. “Ten years from now, this will be the norm,” she says. “Parents will be beating at the door to get their kids in these types of programs”

Many people are already convinced. Today, Adeliz Vicens expresses no misgivings about her child’s experience with Tender Health Care. “I can compare Alexa’s development to another child who stayed home and see how much farther along Alexa is,” she said. “I know it was the right thing.”

Keith Bush is a contributing writer for Dealer/Provider.