Texas Health Steps

Be in the Know:
Private Duty Nursing (PDN) and Prescribed Pediatric Extended Care Centers (PPECCs)

Our vision is for optimal health and quality of life for all children and youth with special health-care needs and their families.

U.S. Department of Health and Human Services, 2020

Fast Facts

  • Nationwide, nearly 19 percent of children 17 years and younger (13.8 million) have a special health-care need
  • In Texas, 17.4 percent of children 17 years and younger (1.2 million) have a special health-care need
  • Nationwide, an estimated 3.2 percent of youth with special health-care needs — or one in every 31— have complex medical conditions

Sources: National Survey of Children’s Health, 2018-2019 & Pediatrics (2018)

Children and adolescents with complex medical conditions such as congenital heart diseases, genetic conditions, cystic fibrosis, cancer and other conditions may require constant nursing care. They also may need medical equipment such as wheelchairs, oxygen concentrators, gastrostomy tubes and medication ports.

“These children and their families often navigate multiple health care providers and are consistently at high-risk for emergency department visits and hospitalizations” (Children's Hospital of Philadelphia, PolicyLab, 2019).

Children and adolescents with complex medical conditions who live at home may require Medicaid-covered home health skilled nursing or home health aide visits to assist with personal care and medical needs.

In Texas, two additional key Medicaid services also are available to youth with complex medical conditions who live in the community:

  1. Private duty nursing (PDN)
  2. Prescribed Pediatric Extended Care Centers (PPECCs)

PDN and PPECC are Texas Health Steps benefits for children and adolescents ages birth through 20 years who meet medical necessity criteria and require individualized, continuous, skilled health care beyond the level of a home health skilled nursing or home health aide visit.

Both of these services could be provided to a youth on the same day. However, individuals cannot receive PDN services during the hours they are in a PPECC, which is a licensed, non-residential care center. For example, a child may receive PDN services in the mornings at home before going to the PPECC and again in the evening or at night after coming home from the PPECC.

PDN and PPECC: Recognizing the Difference

  • Private Duty Nursing

    PDN services must:

    • Be ordered by a physician, advanced practice registered nurse (APRN) or physician assistant (PA).
    • Receive prior authorization.
    • Be provided by an RN or licensed vocational nurse (LVN) working independently or employed by a home health agency enrolled with Texas Medicaid.

    In addition:

    • PDN services may be provided at, but are not limited to, the child’s home, school or day-care center, or the nurse’s home.
  • Prescribed Pediatric Extended Care Centers

    PPECCs are:

    • Licensed, non-residential care centers providing medical, nursing, psychosocial, therapeutic and developmental services appropriate to the individual’s medical condition and developmental status.
    • Available only through a prescription from a physician.
    • Allowed to provide care for an individual up to 12 hours a day if designated in their care plan.
    • Not open overnight. Services are allowed only between 5 a.m. and 9 p.m.
    • Licensed to provide services for four or more individuals with complex medical conditions.

    PPECCs provide children with complex medical conditions opportunities to play, learn and socialize with other children and adolescents in a community-based center while giving their parents or caregivers time to go to work or school or to take care of other key family needs.

    PPECC services are intended as an alternative to PDN services. PPECC services must be a one-to-one replacement of PDN hours unless additional hours are medically necessary.

Review the following case study for an example of how PDN and PPECC services may be appropriate for a young patient with complex medical needs.

Case Study

portrait of young boy
Jaylen 5 years

Jaylen is a new patient of Dr. Gregory at a Rio Grande Valley clinic, having recently moved to town so his family can be closer to grandparents. Jaylen has a neurological disorder with complex health-care needs and has just been discharged following hospitalization for an acute respiratory episode. He experiences daily seizures, has a tracheostomy tube and is incontinent of bladder and bowel.

Jaylen lives at home with his parents and 6-month-old sister. He is eligible for Texas Health Steps and receives 40 hours a week of private duty nursing in addition to care from his mother, mostly during weekdays while his father is at work. On weekends, both parents care for their children. Jaylen's mother has taken a part time job two days a week and tells Dr. Gregory: “We need the income from my new job. I can’t be at home with Jaylen and his nurse on the days I work. But we want him to live at home.”

Click below for action steps that Dr. Gregory can take to ensure Jaylen’s complex medical needs are met while he continues to live at home.

Why It Matters

As a Texas Health Steps provider, you play a vital role in assisting children and adolescents who have medically complex conditions with accessing ongoing therapeutic and nursing care. Youth with complex needs have a choice of PDN, a PPECC, or a combination of both PDN and a PPECC for ongoing skilled nursing. PDN and PPECCs are designed to help youth with complex medical needs live as independently as possible in the community. Your knowledge of these programs and ability to assist families can make a difference in a child or adolescent’s quality of life.

Related Courses


Allshouse, C., Comeau, M., Rodgers, R., & Wells, N. (2018). Families of Children With Medical Complexity: A View From the Front Lines. Pediatrics, 141(Supplement 3), S195-S201.

Children’s Hospital of Philadelphia, PolicyLab. (2019). Meeting the Needs of Children with Complex Medical Needs in a Changing Health Care System.

Texas Department of State Health Services. (2019). Children and Youth with Special Health Care Needs 2018 Outreach Survey Report.

Texas Health and Human Services Commission. (2021). Prescribed Pediatric Extended Care Centers (PPECCs).

Texas Medicaid & Healthcare Partnership. (2021). Texas Medicaid Provider Procedures Manual.

Texas Medicaid Provider Procedures Manual, Children’s Services Handbook, 2.14. Prescribed Pediatric Extended Care Centers.

Texas Medicaid Provider Procedures Manual, Home Health Nursing and Private Duty Nursing Services Handbook.

U.S. Department of Health and Human Services, Health Resources & Services Administration. (2020). Children and Youth with Special Health Care Needs.