Demographics and financial impact of home respiratory care

Healthcare policymakers, governmental and private alike, are now faced with an enormous challenge. Demands for improved access to cost-effective and high quality healthcare are emanating from all segments of our society. Clearly, the traditional model of admitting patients to an acute care hospital as a first-line intervention is losing favor. Although there will always be a role for acute hospital care, utilization of this high-cost setting must be better managed if runaway healthcare costs are to be brought under control. The concept of moving patients along the healthcare continuum as their response to treatment reduces the acuteness of their condition is rapidly gaining support, especially with third-party payors. Accordingly, home healthcare providers, including those offering respiratory home care services, can expect to see an increase in the number of referrals they receive. HME/RT providers must actively promote the benefits they can offer in terms of high quality, cost-effective outcome. It is not unrealistic to suggest that the savings realized by reducing an acute hospital stay by 1 day can easily cover the costs of providing respiratory home care for 4 to 6 weeks. One can only hope that such compelling arguments, occurring at a time when healthcare reform and restructuring is a national priority, will translate to more equitable reimbursement guidelines for respiratory home care providers. The past practice of only reimbursing for equipment and supplies fails to take into account the vital role played by the home respiratory therapist. Home respiratory equipment and supplies, while an important component of managing chronic respiratory disease, are only effective if used safely, properly, and in compliance with the prescribing physician's intentions. The use of skilled and dedicated home respiratory therapists to train patients, monitor and assess outcomes, and communicate with the prescribing physician ensures optimum results. It is time for reimbursement policies to recognize this vital role played by home respiratory therapists.     

The effect of home respiratory therapy on hospital readmission rates of patients with chronic obstructive pulmonary disease.

The South Hills Health System Home Health Agency, Homestead, Pennsylvania, studied the effect of home respiratory therapy on hospital readmission rates in 418 patients with chronic obstructive pulmonary disease (COPD). Respiratory therapists evaluated and followed referred patients in their homes. Oxygen, breathing equipment, and supplies were provided, and patients were educated in use, cleaning, and maintenance of equipment. Data for the study were taken from hospital records, home assessments, and discharge summaries. All patients studied had been hospitalized in the year prior to receiving home respiratory therapy. After 12 months of follow-up, 64% had not been rehospitalized. In the year prior to home respiratory therapy, the average number of hospital admissions per patient had been 1.28, with the average length of hospital stay being 18.25 days. During the home respiratory therapy study period of 12 months, the average number of hospital admissions was 0.48, with the average length of hospital stay being 6.09 days. These results indicate that home care provided by respiratory therapists can significantly reduce the rehospitalization of COPD patients. Prevention of rehospitalization in the study group resulted in estimated average hospital costs of savings of $2,625 per per patient for the year. As a result of this study, two large local industrial employers, the Federal Black Lung program, and Blue Cross of Western Pennsylvania have added respiratory therapy to their home health benefits.     

Changing patterns of inpatient respiratory care services over a decade at the Cleveland Clinic: challenges posed and proposed responses

INTRODUCTION: Changing characteristics of hospitalized patients over the last decade have created challenges for all health-care providers in delivering optimal care. In the specific case of respiratory care, trends that hospitalized patients have generally become sicker over time and that average lengths of stay have generally become shorter have posed the challenge of meeting demands for more services delivered with greater immediacy. We undertook the current analysis to assess how the delivery of respiratory care services at a tertiary-care academic medical center, the Cleveland Clinic Foundation Hospital, has evolved over the decade 1991 to 2001. In this observational study, we examined concurrent departmental trends and speculated that the capability to increase clinical activity with maintained or improved clinical outcomes, preserved costs, and a lower turnover rate among respiratory therapists reflects features of the professional environment within our Section of Respiratory Therapy. METHODS: This analysis compares patterns of respiratory care service delivery in two 5-year intervals: from 1991 to 1996 and from 1996 to 2001. Data were collected using a respiratory care information-management system and an inpatient hospital information system, which track the volume and actual cost of services provided. These analyses accounted for the actual time-based cost of the services, including labor (with benefits), necessary equipment and supplies, medications, and equipment maintenance and depreciation. Hospital case-mix index values were determined according to guidelines from the Centers for Medicare and Medicaid Services, as the weighted average of resource allocation scores assigned to diagnosis-related-group categories of hospitalized patients. RESULTS: From 1991 to 2001, there were important expansions in the scope of respiratory care practice by our Section of Respiratory Care, while the volume of respiratory care services delivered per year increased 1.96-fold (from 339,600 to 665,921 services/y). The number of respiratory therapy consults performed yearly, beginning in 1992 when the service was first implemented, rose to over 10,000/y by 2001. At the same time, the cost of respiratory therapy services delivered per patient decreased by 4.2%. Regarding staffing trends, the number of full-time-equivalent employees increased by 50% (from 65 to 97.5). However, the percent turnover rate among respiratory therapists decreased by 2.3-fold (from 11.5% to 5%). In the face of these trends, the hospital mortality rate for patients with diagnosis-related group 088 (high users of respiratory care services) decreased by 53%, and the length of hospital stay for all patients receiving respiratory treatments decreased by 30%. CONCLUSIONS: This analysis shows that trends of growing demands for respiratory care services have been accompanied by generally improving clinical outcomes and favorable retention of respiratory therapists in our section. We believe that a focus on the process of care, including enhanced professionalism, communication, and participation, has permitted a favorable response to these rising demands.     

Respiratory care protocol: an approach to in-hospital respiratory therapy.

The difficulty of delivering respiratory therapy according to currently accepted standards is an important problem in many hospitals. As a result of this problem in our hospital, we developed a new therapy delivery system--the Respiratory Care Protocol. In response to an order for Respiratory Care Protocol from an attending physician, a senior respiratory therapist evaluates the patient, prescribes specific respiratory therapy according to a protocol, and then daily re-evaluates the patient and makes appropriate therapeutic changes, including discontinuing respiratory therapy when appropriate. The Respiratory Care Protocol has been well-accepted by patients, physicians, and respiratory therapists, and by Joint Commission on Accreditation of Hospitals evaluation teams. We believe that our use of the Respiratory Care Protocol has led to improved quality and to the reduced cost of our in-hospital respiratory care.     

Home respiratory therapy for patients with chronic obstructive pulmonary disease.

The goals of the South Hills Health System Home Health Agency's program of home respiratory therapy for patients with chronic obstructive pulmonary disease are to support life; to improve physical, emotional, and social well-being and productivity; to promote patient and family self-sufficiency; to provide respiratory care of high quality; and to ensure the cost effectiveness of respiratory therapy services. In the patient's home, qualified respiratory therapists perform respiratory assessments, deliver and supervise respiratory therapy treatments and related procedures, and educate patients and their families. This program of home respiratory care has been shown to be a cost-effective solution to the care of homebound patients with chronic obstructive pulmonary disease.     

Administrative and professional issues for the occupational therapist in home health care

Administrative and professional issues for the occupational therapist working in home health care include contractual relationships, referral systems, third-party reimbursement, documentation, equipment, and ethics. In this paper, the regulations for third-party reimbursement by Medicare, Medicaid, and Blue Cross for occupational therapy in home health care are explained, including the Medicare definition of homebound status and the requirement that treatment be restorative. The effect of such regulations on occupational therapy treatment planning and documentation of services is discussed. Coverage of frequently ordered equipment by Medicare and Medicaid is explained. Both the issues related to standards of practice, including the length and frequency of occupational therapy treatment sessions, and the expected duration of treatment are discussed. The effect on the professional relationship of treating patients in their own environments is examined. Changes in third-party reimbursement for inpatient care have presented occupational therapists with the challenge of working with acutely ill patients in their homes.     

Legislation and respiratory rehabilitation.

The provision of respiratory rehabilitation services has been frustrated by legislative and regulatory omissions and struggles. The original Medicare and Medicaid statutes did not mention respiratory therapy services, a fact that has excluded reimbursement for such services in the home. However, the Health Care Financing Administration (HCFA) has ruled that outpatient rehabilitation is a reimbursable service, a point about which third-party payers sometimes have to be reminded. In 1980 the Medicare program was adjusted to provide for the creation of comprehensive outpatient rehabilitation facilities (CORFs); the statute written then is the first to mention "respiratory therapy" as a reimbursable service. In 1982 regulations were published that included a detailed definition of recognized respiratory therapy services, and more recently HCFA released implementing regulations to fiscal intermediaries. However, the home care aspect of respiratory rehabilitation remains a legislative stepchild, permitting only one home evaluation visit, even though it has been reported in the literature that home respiratory care can be a cost saver. Home care by respiratory therapists probably will come, but experience shows that the Federal regulation maze can be very difficult to negotiate, especially in the face of opposition by the Administration.     

Putting infection control principles into practice in home care.

Implementing sound, rational infection control practices in home care has been challenging since guidelines, standards, and most references have been developed for the acute care setting. This article provides guidance for adapting appropriate infection control interventions for patient care practices to the home care setting. Such practices include handwashing, home infusion therapy, respiratory care, wound care, urinary tract care, and isolation precautions. Assessment of the home care environment, cleaning and reprocessing of equipment, surveillance, implications for occupational health, and program design are also discussed.     

The future of respiratory care

The term respiratory care has more than one meaning, referring both to a subject area within clinical medicine and to a distinct health care profession. In the light of several fundamental transformations of health care during the 20th century, this article reviews the history of respiratory care in both of these contexts and offers 10 predictions for the future: (1) Less focus on raising P(aO2) as a primary goal in managing patients with acute hypoxemic respiratory failure. (2) More attention to the adequacy of tissue oxygenation in such patients, irrespective of P(aO2), and the emergence of "permissive hypoxemia," analogous to permissive hypercapnia, in managing them. (3) Smarter monitors that display information less but process it more, while interacting directly with ventilators and other devices to modify therapeutic interventions. (4) Increased use of and expertise with noninvasive ventilation, with a corresponding decrease in intubations and complications, in treating patients with acute exacerbations of COPD. (5) Increased use of triage in the intensive care unit, including earlier determination of the appropriateness of maximal supportive intervention. (6) Greater use of protocols in patient assessment and management, in all clinical settings. (7) Increased awareness of, expertise in, and resources for palliative care, with a more active and acknowledged role for respiratory therapists. (8) Accelerating progress in smoking cessation and prevention, and also in early detection and intervention in COPD, led by the respiratory care profession. (9) An increasing presence and impact of respiratory therapists as coordinators and care givers in home care. (10) A continued and enlarging role for the journal Respiratory Care in disseminating research findings, clinical practice guidelines, protocols, and practical educational materials in all areas of the field.     

Physician-ordered respiratory care vs physician-ordered use of a respiratory therapy consult service: early experience at The Cleveland Clinic Foundation

BACKGROUND: Accumulative evidence suggests that respiratory care is frequently misallocated. We report the results of a pilot study of a delivery system aimed at correcting such misallocation. METHODS: The delivery system (Respiratory Therapy Consult Service, or RTCS) allows respiratory therapists (when requested by the case-managing physician) to determine respiratory care, with decisions guided by algorithm (ie, Consult patients). In the pilot study, Therapist Evaluators responded to requests for Consults on two study wards. All staff therapists participated in implementing Evaluator-determined treatment. STUDY DESIGN: We evaluated 38 patients (20 of whom were Consult patients) randomly selected from a total of 82 patients undergoing abdominal surgery during the study period. RESULTS: Consult patients were significantly older than non-Consult patients, more likely to be heavy smokers (67 vs 43%), and sicker as suggested by a higher Triage Score. Consult patients received more types and more total respiratory care services, demonstrated a trend toward longer stay, and had significantly higher respiratory therapy charges. CONCLUSION: Our experience shows that a consult program can be successfully implemented in a large, tertiary care institution with widespread physician and nursing support. Whether the RTCS fulfills its goal of ameliorating misallocation of respiratory care has yet to be proven and awaits the completion of other studies currently under way.     

Use of a computerized respiratory care record system to study utilization of IPPB therapy.

Increases in the utilization of respiratory therapy and the need to avoid its misuse have placed increasing management responsibilities on medical and technical supervisors of respiratory care services. To improve our managerial capabilities we designed a computerized respiratory care record system. Respiratory therapists use specially designed forms to record initial respiratory assessments and subsequent progress notes. A computer program allows secretaries to enter information from the forms into a data base. Another program tabulates information from the data base. As an example of the usefulness of this system we present a study of the utilization of intermittent positive-pressure breathing (IPPB) therapy in patients undergoing intrathoracic or upper abdominal surgery. Although all such patients were routinely educated preoperatively in the use of IPPB, chest physiotherapy, and incentive spirometry, the study revealed that only 14% of the patients received IPPB postoperatively, whereas more than 90% received chest physiotherapy and incentive spirometry. As a result of our findings we are saving time and money by discontinuing routine IPPB education for this population.     

Planning for successful home mechanical ventilation

Home mechanical ventilation has evolved to permit discharge of patients on portable negative or positive pressure mechanical ventilators. Assessment of the patient for home discharge is initiated by a multidisciplinary team. The nurse, physician, social worker, respiratory therapist, speech therapist, occupational therapist, home health nursing agency, durable medical equipment supplier, and caregivers constitute the team. The crucial links to a successful patient discharge are an involved family and a well-developed plan of care, although patient finances also are important. The nurse develops, coordinates, and implements the teaching plan over a period of 2 or more weeks. The home caregivers provide total care for the patient several days before discharge. The home health agency and the durable medical equipment supplier provide services which ease the transition of care from hospital to home. One alternative to home discharge is placement in an extended care facility.     

Home respiratory care

In 1980, 11,000 French patients were given home respiratory care (HRC); today there are ten times more cases, i.e. about 120,000. There are two principal conditions in this population: chronic severe lung disease (CSLD), treated mainly with long-term oxygen therapy and assisted ventilation, and sleep apnoea syndrome (SAS), treated with continuous positive airway pressure (CPAP), a treatment that first became available in 1985. The mean age of patients with CSLD is currently 67 years and is increasing annually, while for SAS it is 58 years. The constraints of treatment, prescribed for the rest of the patient's life, are incompatible with long-term hospitalization, given the daily length of treatment (12-24 h for CSLD, and 5-8 h at night for SAS). The number of medical and social workers involved in providing these types of treatment requires complex coordination for the patient to be able to benefit from such highly cost-effective medical and technical services. In the case of home respiratory care, France has benefited for almost twenty years from the services of a not-for-profit network that comprises a national coordinating body, ANTADIR, and regional HRC services administered by physicians specializing in pneumology or resuscitation, often from university hospitals.     

The impact of computer-age technology on respiratory therapy.

Computer-age technology is changing the face of respiratory therapy as it is that of nearly every other technical field. In some hospital respiratory therapy departments computers are presently being used for a wide range of functions such as blood gas result reporting, billing, budgeting, purchasing, hemodynamic calculations, and respiratory monitoring. Microprocessor-controlled ventilators and respiratory monitoring systems are becoming increasingly utilized. In the future the computer may actually operate the ventilator. But who is going to operate the computer? The new breed of intensivist will be trained in critical care medicine, respiratory therapy, biomedical engineering, and computer technology. Respiratory therapists must recognize and rise to the challenge that computer-age technology presents if they are to continue as intensivists. The worst possible development of the future for respiratory therapy would be for computer-age technology to be applied to respiratory therapy without the input and inclusion of respiratory therapists. The challenge then is to be adequately prepared to utilize and apply this inevitable new computer-age technology.     

Home care of the ventilator-dependent person.

Discharge of the ventilator-dependent person from a hospital requires careful advance planning by hospital personnel and rehabilitation of the patient to assure maximal functional ability in the home. The patient and family should be taught the techniques necessary for both routine and emergency care in the home. Respiratory equipment, including the type of mechanical ventilator best suited to the patient's needs and the home environment, and disposable supplies must be obtained, and payment from third-party payers must be assured. Equipment placement and the ability of the patient to perform self-care and activities of daily living following discharge can be facilitated by integrating results of a home care evaluation into the patient's rehabilitation program. Trips of gradually longer duration out of the hospital allow the patient to gain confidence in his ability to care for himself. Responsibilities for follow-up in the home can be shared by respiratory home care companies, visiting nurses, and pulmonary physicians.     

An assessment of the appropriateness of respiratory care delivered at a 450-bed acute care Veterans affairs hospital

INTRODUCTION: Respiratory care is expensive and time-intensive, inappropriate care wastes resources, and failure to provide necessary and appropriate respiratory care may adversely affect patient outcomes. OBJECTIVE: To determine the appropriateness of basic respiratory care delivered at a 450-bed Veterans Affairs hospital during a 3-month interval. METHODS: We determined (1) the percentage of delivered respiratory care that was not indicated (based on standardized clinical practice guidelines), (2) the percentage of respiratory care that was indicated but not ordered (based on standardized clinical practice guidelines), and (3) the labor cost and potential savings of protocol-based respiratory care at our hospital. We selected 5 assessment days, occurring at 2-week intervals. All patients who received basic respiratory care underwent a complete respiratory care assessment, including medical records review, patient interview, physical assessment, and measurement of blood oxygen saturation (via pulse oximetry) and inspiratory capacity. Intensive care patients were excluded from the study. The assessment instrument provided a standardized format based on American Association for Respiratory Care clinical practice guidelines. RESULTS: We assessed 75 patients. A mean of 24.8% of the delivered respiratory therapies reviewed were not indicated. The percentages of ordered but not indicated therapies were: oxygen 17.7%; all categories of aerosolized medications (bronchodilators, mucolytics, anti-inflammatory agents) 32.4%; chest physiotherapy 37.5%; lung expansion therapy 7.7%. A mean of 11.8% of the patients assessed were not receiving respiratory care that was indicated. The percentages of indicated but not ordered therapies were: oxygen 5.3%; bronchodilator 5.3%; lung expansion therapy 36%. CONCLUSION: A mean of 24.8% of the basic respiratory care procedures delivered were not indicated and 11.8% of patients were not receiving care that was indicated. Inappropriate utilization of respiratory care services may increase costs and adversely affect morbidity, mortality, and duration of stay. We believe that implementation of respiratory care assessment protocols based on nationally accepted clinical practice guidelines can reduce unnecessary care, optimize care delivered, and may reduce costs and improve outcomes.     

Respiratory care management information systems

Hospital-wide computerized information systems evolved from the need to capture patient information and perform billing and other financial functions. These systems, however, have fallen short of meeting the needs of respiratory care departments regarding work load assessment, productivity management, and the level of outcome reporting required to support programs such as patient-driven protocols. The respiratory care management information systems (RCMIS) of today offer many advantages over paper-based systems and hospital-wide computer systems. RCMIS are designed to facilitate functions specific to respiratory care, including assessing work demand, assigning and tracking resources, charting, billing, and reporting results. RCMIS incorporate mobile, point-of-care charting and are highly configurable to meet the specific needs of individual respiratory care departments. Important and substantial benefits can be realized with an RCMIS and mobile, wireless charting devices. The initial and ongoing costs of an RCMIS are justified by increased charge capture and reduced costs, by way of improved productivity and efficiency. It is not unusual to recover the total cost of an RCMIS within the first year of its operation. In addition, such systems can facilitate and monitor patient-care protocols and help to efficiently manage the vast amounts of information encountered during the practitioner's workday. Respiratory care departments that invest in RCMIS have an advantage in the provision of quality care and in reducing expenses. A centralized respiratory therapy department with an RCMIS is the most efficient and cost-effective way to monitor work demand and manage the hospital-wide allocation of respiratory care services.     

The impact of turnover among respiratory care practitioners in a health care system: frequency and associated costs

BACKGROUND: Retention of respiratory therapists (RTs) is a desired institutional goal that reflects department loyalty and RTs' satisfaction. When RTs leave a department, services are disrupted and new therapists must undergo orientation and training, which requires time and expense. Despite the widely shared goal of minimal turnover, neither the annual rate nor the associated expense of turnover for RTs has been described. STUDY PURPOSE: Determine the rate of RT turnover and the costs related to training new staff members. METHODS: The Cleveland Clinic Health System is composed of 9 participating hospitals, which range from small, community-based institutions to large, tertiary care institutions. To elicit information about annual turnover among RTs throughout the system, we conducted a survey of key personnel in each of the hospitals' respiratory therapy departments. To calculate the costs of training, we reviewed the training schedule for an RT joining the Respiratory Therapy Section at the Cleveland Clinic Hospital. Cost estimates reflect the duration of training by various supervisory RTs, their respective wages (including benefit costs), and educational materials used in training and orientation. RESULTS: Turnover rates ranged from 3% to 18% per year. Five of the 8 institutions from which rates were available reported rates greater than 8% per year. The rate of annual turnover correlated significantly with the ratio of hospital beds to RT staff (Pearson r = 0.784, r(2) = 0.61, p = 0.02). The cost of training an RT at the Cleveland Clinic Hospital totaled $3,447.11. CONCLUSIONS: Turnover among respiratory therapists poses a substantial problem because of its frequency and expense. Greater attention to issues affecting turnover and to enhancing retention of RTs is warranted.     

Conference summary: computers in respiratory care

Computers and data management in respiratory care reflect the larger practices of hospital information systems: the diversity of conference topics provides evidence. Respiratory care computing has shown a steady, slow progression from writing programs that calculate shunt equations to departmental management systems. Wider acceptance and utilization have been stifled by costs, both initial and on-going. Several authors pointed out the savings that were realized from information systems exceeded the costs of implementation and maintenance. The most significant finding from one of the presentations was that no other structure or skilled personnel could provide respiratory care more efficiently or cost-effectively than respiratory therapists. Online information resources have increased, in forms ranging from peer-reviewed journals to corporate-sponsored advertising posing as authoritative treatment regimens. Practitioners and patients need to know how to use these resources as well as how to judge the value of information they present. Departments are using computers for training on a schedule that is more convenient for the staff, providing information in a timely manner and potentially in more useful formats. Portable devices, such as personal digital assistants (PDAs) have improved the ability not only to share data to dispersed locations, but also to collect data at the point of care, thus greatly improving data capture. Ventilators are changing from simple automated bellows to complex systems collecting numerous respiratory parameters and offering feedback to improve ventilation. Clinical databases routinely collect information from a wide variety of resources and can be used for analysis to improve patient outcomes. What could possibly go wrong?