The Family CNA Model: Supporting Families and Improving Care for Children With Medical Complexity

Below is an excerpt from a paper on the developed by Manatt Health, with support from Team Select Home Care and in partnership with Family Voices, Health Leads, and the Lucile Packard Foundation for Children’s Health. Click  to read the full paper and analysis.

Children with medical complexity represent less than 1% of all children in the U.S., but have significant, specialized, and long-term health care needs, accounting for one-third of pediatrics costs in the U.S. This group of children have one or more chronic and/or complex medical conditions—such as cerebral palsy, muscular dystrophy and seizure disorders—that result in functional limitations and/or dependence on in-home nursing support and medical devices like a ventilator. Care for children with medical complexity is not only costly but also too often difficult for families to access. Yet, without this care, children with medical complexity are at higher risk of emergency room visits, hospitalization, and even moving into an institutional setting, away from their homes, families, and communities.

The well-documented national home care workforce shortage is leaving families of children with medical complexity struggling to balance all of the challenges that come with caring for their child, chief among them finding the right care for their child in their homes. Home health agencies, for example, reported turning away over 25% of referred patients due to staff shortages in 2023. When families can’t find providers for their children, family members are often forced to leave the workforce to fill the gap, without compensation for the care they provide to their child.

There is an urgent need to expand access to care delivery models that keep children with medical complexity in their homes and out of costly hospital or institutional settings, while supporting families’ financial security. A small but growing number of state Medicaid programs are adopting the Family Certified Nursing Assistant (CNA) model to do just that.

The Family CNA model trains and reimburses family members—including parents, guardians, siblings, aunts, uncles, and grandparents—to provide certain types of home care for children with medical complexity that would otherwise be provided by a registered nurse (RN), a licensed practical nurse (LPN), or a non-family CNA. This care includes low acuity in-home nursing tasks, such as medication administration, gastronomy tube (G-tube) care, or catheter care. Family CNAs are licensed or certified health care professionals that work in concert with other providers on a child’s care team, including RNs and LPNs who provide supervision and perform high-acuity tasks, to support their child’s medical needs and activities of daily living at home. The unique benefits of the Family CNA model include:

1. Addressing critical home care workforce shortages by increasing the number of trained and compensated caregivers and freeing up RNs and LPNs to operate at the top of their credentials and serve more patients.
2. Improving the continuity and quality of care for children with medical complexity. Family CNAs receive, at minimum, the same training as non-family CNAs, and in some states receive additional training on skilled tasks such as feeding tube care and tracheostomy care. Additionally, as family members, they maintain a close and lifelong connection to their child.
3. Strengthening families’ agency and supporting financial security. Giving family members the technical skills and support they need to provide person-centered care while compensating them for their time improves the well-being of the entire family.

The Family CNA model also has cost-saving potential for states, by preventing avoidable or prolonged hospitalizations and by freeing up RNs and LPNs to provide care at the top of their licenses. A recent analysis by the Oklahoma Medicaid agency found that implementing a Family CNA program could save more than $3 million annually.

There is bipartisan support and momentum at both the federal and state levels to acknowledge the value of family caregivers and better support them as part of a multi-pronged strategy to address the national home care workforce shortage and, in turn, improve care for children with medical complexity. While Medicaid priorities and policies are in a dynamic state, there are actions federal and state policymakers can take to build on that momentum of support for family caregivers and expand access to the Family CNA model. These actions, discussed in more detail in , include:

1. Building a coalition of key constituencies, including families and their advocates, providers, nursing boards, and policymakers, to support and design state Family CNA programs that meet the needs of children with medical complexity in their state, proactively address barriers to implementation, and produce positive outcomes.
2. Identifying appropriate Medicaid authorities available to states to implement the Family CNA model and collaborating with coalition partners to monitor and evaluate the model’s impact.
3. Issuing federal guidance to states on a standardized definition, training, and coding and billing procedures for family CNAs.

States that newly adopt the model will have the advantage of learning from existing Family CNA programs as well as other national family caregiver initiatives under way. More families with access to the Family CNA model will mean more families are trained to care for their children with medical complexity while also receiving appropriate support and oversight to provide high-quality care. Click to read the full analysis and recommendations.

The home care workforce shortage is also impacting the ability of seniors and people with disabilities to find the care and support they need to remain in their homes and communities.

Medicaid is the largest payer of long-term services and supports (LTSS)—this paper uses the term “long-term care”—in the United States. In 2022, Medicaid paid for 61% of all LTSS spending in the U.S. and 69% of home and community-based services, a subset of LTSS. .

American Academy of Pediatrics. Children with Medical Complexity. 2024.

Home Care Association of America and National Association for Home Care & Hospice. The Home Care Workforce Crisis: An Industry Report And Call To Action. March 2023.

Oklahoma Legislature. Senate Fiscal Summary; Senate Bill 56. 2025.