Closing the Measurement Gap in Pediatric Home-Based Care

​Children with medical complexity (CMC) represent approximately 1% of the U.S. pediatric population, yet account for a disproportionate share of healthcare utilization and cost—including hospitalizations, inpatient days, and total charges. Despite this, care delivery remains heavily weighted toward hospital-based settings, with limited investment in home health services.

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This imbalance is sustained in part by the absence of a standardized, psychometrically sound assessment tool capable of objectively communicating the clinical acuity, complexity, and skilled nursing intensity required to safely care for these children in the home. Without such a tool, the expertise of pediatric nurses—particularly those managing technology-dependent children—remains difficult to quantify, limiting visibility to payers, regulators, and utilization management systems.

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​The Measurement Gap: Why Existing Tools Fall Short

Existing pediatric home health assessment tools are not standardized across states, lack psychometric validation, and are not designed to communicate patient complexity in a way that supports external review and authorization processes.

They fail to capture the full dimensionality of care required for CMC, including:

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• Clinical acuity and diagnostic complexity

• Technology dependence

• Functional and developmental status

• Social determinants of health

• Family caregiver capacity and health behaviors

• Cognitive workload of the nurse

• Time required for direct care and care coordination

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In the absence of a comprehensive and validated framework, skilled nursing determinations are often based on incomplete clinical information—contributing to care variability, disparities in access, and avoidable utilization.

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Meeting this Critical Need: Developing PATHH

Aveanna Healthcare led the development of the Pediatric to Adult Assessment Tool for Home Health (PATHH)—a standardized, evidence-based instrument designed for the private duty nursing setting and aligned with CMS National Quality Strategy priorities.

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PATHH was developed through a rigorous, multi-phase process that included:

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• Systematic review of pediatric literature and clinical best practices

• Analysis of CMS and multi-state Medicaid guidance

• Review of authorization tools across more than 40 states

• A modified Delphi process engaging more than 300 clinical leaders

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The framework incorporates a comprehensive, systems-based assessment spanning respiratory, cardiovascular, neurologic, endocrine, mobility, medication, and environmental domains—aligned with nursing scope of practice and informed by both evidence and real-world care delivery.

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Validation and Real-World Implementation

PATHH was tested and refined through four phases of field application, progressing from pilot testing to multi-state implementation:​

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• Pilot testing with RN clinicians using de-identified cases

• Expanded testing across broader clinician groups

• Multi-state deployment involving 200 RNs conducting more than 1,800 patient assessments across 63 locations

• Final validation including Content Validity Index (CVI) testing, regulatory review, and EMR integration planning

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This process resulted in a deployment-ready instrument supported by a multi-year evidence base and a practitioner-informed development model without precedent in the PDN setting.

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​Summary Illustration of PATHH Development Process​​​​​​​