Disease management providers are discovering that properly trained RCPs may be the key to cost-effective and improved respiratory home care.

Such has been written about the important role the RCP plays in the management team for the home respiratory therapy patient. As the health care dollar continues to shrink, RCPs strive for marketability or viability in an ever-changing health care market. Therapists are asked to provide services with fewer staff while providing clients with quality care. Many therapists have chosen to work in an alternate care setting. Home care is becoming a rewarding career choice for many RCPs either as a full-time option or as a way to supplement an income.

When I began my home care career, it was with a moderately sized durable medical equipment (DME)/home respiratory company, which was later purchased by a larger DME company, which then merged with another home care company, etc. Those early days were filled with monthly visits, which consisted of checking the patient’s oxygen concentrator, changing the cannula, perhaps taking out the patient’s trash, feeding the cat or dog, fixing an occasional meal, and sometimes sitting down to a cup of coffee and a lengthy conversation. As the years have past, we all are becoming quite aware of the impact that Medicare, Medicaid, and managed care have had on the way home care companies provide services to their respiratory patients. Although I have been an account executive and have served in primarily a sales role for the past 12 years, which involves educating the referral community on the services that my company could provide, I have continued to see patients in the home in order to better understand the challenges facing the client, the home care company’s management staff, and the payor of the services rendered.

Making a Change
I made a significant change in my career 2 1/2 years ago when I went to work for a home health agency/home infusion company. This agency was a start-up branch, which provided significant opportunities for flexibility in delivery of care. The agency’s management team is very patient care and service oriented, utilizing tenured staff with years of home health care experience. Although the core management staff had primarily a home infusion therapy background, that experience would prove to be a valuable resource for the type of clients that the agency would begin to see and the delivery of care those clients would require.

The director of the home health agency, Ofelia Santiago, is a certified registered infusion nurse and a certified case manager with an energetic, positive, and innovative attitude about the quality of care that can be delivered in the home. She believes in providing the best clinician to fit the needs of a particular client. Her refreshing ideas and willingness to do what was not necessarily the home health agency “norm” provided a challenging and rewarding experience for those who have had the privilege of working with her. I learned very quickly that managed care did not necessarily need to mean a negative.

By managing client health care resources, quality patient care could be delivered in an effective, cost-controlled manner in which the client, managed care organization, and home health agency could obtain satisfaction with the care delivered and desired outcomes obtained. But to fully understand the important impact that a good home respiratory therapist can have on a home health agency in the delivery of quality care, you must first understand some of the history and the many challenges facing traditional home health agencies. Changes are occurring not only with the traditional agencies, but also throughout the health care industry as a whole.

The RCP’s Role in Home Care
Traditional home health care has included skilled nursing, occupational and speech therapy, and physical therapy. It might include assistance with dressing, bathing, self-administered medications, meal preparation, and housekeeping. Home health care covers the beneficiary with a physician’s order, and if they qualify, under guidelines for the use of assistive devices such as walkers, hospital beds, wheelchairs, and, of course, oxygen. Home health care is usually medically oriented and is different from, say, a homemaker or personal care service. Traditionally, registered and licensed practical nurses, physical, occupational, and speech therapists, and home health aides give care. Implementation of the Tax Equity and Fiscal Responsibility Act of 1981 determined how a home health agency would be paid. An agency would be paid by Medicare and Medicaid for home health visits if all the following conditions were met:

1. The client must be homebound;

2. In need of intermittent skilled nursing care, or physical therapy, or speech therapy;

3. Under the care of a physician who determines there is a need for home health care and sets up a home health plan of care;

4. The home health agency providing the care is Medicare certified; and

5. The client meets the age and resource eligibility guidelines when using Medicaid. Payment to the home health agency was determined by a cost report and varied from agency to agency.

In 1983, when hospitals were provided with a list of diagnosis-related groups (DRGs), we began to see sicker patients being discharged early from the acute care setting to alternate care settings. Under the current system, home health agencies have had to deal with a shift from retrospective case per day payment to a prospective case per day payment for Medicare clients. Agencies that were rewarded by payment according to the number of visits provided per day are now finding that that mentality is no longer cost-effective and are having to become more prudent managers or are closing their doors altogether.

The agency that I am associated with, being relatively new to the area, benefited by having a management staff that was accustomed to working with case managers and believed that the clients/caregivers should be self-sufficient, thereby decreasing the number of visits and saving benefits. The quality of care was not sacrificed; on the contrary, our surveys indicate that clients are very satisfied with the care they receive.

Complex Care Management
As Care IV was designing our strategic plan for the area along with home IV therapy and home health care, we determined that we needed our own niche. An area we chose to pursue was complex care management. Clients are being discharged to the home sicker and using more complex equipment. Many of these clients are complex respiratory therapy patients. An RCP involved with home care for a number of years offered the experience the agency would need to provide this area of expertise. This also meant starting from scratch with our payor contracts, which needed to be negotiated and signed. As we outlined our core home infusion services and traditional home health care services, we also included respiratory therapy services in our payor contracts. Rates for in-home respiratory therapy visits were included and contracts were signed and implemented. It was then time to develop a marketing plan to present to the community.

We received our first complex respiratory therapy case in October 1997. With its team approach of a home nurse, home respiratory therapist, and pharmacist to physicians and case managers, Care IV has demonstrated that a significant impact can be made on saving health care dollars by utilizing the appropriate clinician at the bedside in the home. Having the right RCP is critical when providing hands-on care in the patient’s home. I have found that these therapists must have a unique combination of intensive care, home care, and assessment skills. Remember that the goal is to keep these complex respiratory clients out of the acute care setting and at home. The therapists must have an excellent rapport with the physician community and a recognized competency in order to provide appropriated intervention in the home. Care IV has an RCP on call 24 hours per day. I am the only full-time RRT. The remaining staff of seven RRTs have full-time jobs in other settings. Maintaining full-time jobs in acute care facilities actually acts as a benefit to our organization by keeping the skill levels of these RCPs at an optimal level.

Using A Hands-On Approach
Our clinical director has described many of the clients and environments that we are involved with as ICUs without walls. Many times this therapist has provided interventions in the home that have kept these respiratory clients out of the emergency department and perhaps prevented expensive hospitalization. Our respiratory clients include children to adults, total ventilator patients to intermittent ventilator patients, tracheostomy patients, nontracheostomy patients, and everything in-between. We have expanded services to include an asthma disease management program at home and arterial blood gas draws at alternate sites such as independent sleep laboratories and long-term care facilities. The therapists have proved to be an invaluable resource to our nursing staff, providing respiratory assessments, tracheostomy tube and tracheostomy button changes, equipment instruction, and overall support to the nursing staff. For RCPs who want to be involved in home care, it can be quite rewarding because they really do use many of the skills we were taught in school with a more “hands on” approach.

As with any new endeavor, we have faced our challenges. RCPs have had to learn how to communicate with case managers at the payor level. I believe this is an area that could use significant improvement. We are not the best at documentation. Case managers are looking for an end point to care. As therapists, we are virtually acting as the case managers for our respiratory patients on a daily basis and the procedures that we perform and the education we are doing routinely for these patients are essentially case management; however, the how-to of the documentation of these results or the care plan for the respiratory patients we are seeing is not included in most respiratory therapy curricula in significant enough detail to be helpful to most home respiratory therapists. The nurses in our organization have been very helpful in educating our therapists on preparing care plans that will be useful for the case managers of the payors we work with.

What’s Next
Care IV also has a private duty license that allows the organization to provide extended visits (longer than 4 hours). Through this segment of our business, we provide nursing support for the ventilator clients that we are currently servicing. Our ventilator clients receive care anywhere from 10 to 24 hours per day. Care IV is now exploring the option of teaching RCPs the care these clients require, which would allow respiratory therapists to do shift work with ventilator clients in the home. Currently, if the organization gets in a pinch and we have a nurse that is not comfortable with ventilators, we would send an RCP along to make up a team to care for that particular client. It would be much more cost-effective for our organization if we had the option of using RCPs who could do that type of shift work as long as they have been properly trained. There are many RCPs who have been very enthusiastic about the possibility of doing this type of work.

The potential for using RCPs in the development of disease-specific product lines and care paths has not been fully explored. This area will provide significant opportunities for the therapists who are willing to pave the way and expand the role of respiratory therapy. Therapists are comfortable with the education of the client, understanding the issues of compliance and the demands that chronic diseases make on the individual and their caregivers. These are both the best and the worst of times. I, personally, am looking forward to the new millennium and the opportunities that RCPs will have in the home and alternate care settings.

Gina Marshall, BS, RRT, RCP, is an account executive and respiratory care manager at Care IV Home Health & Infusion Services, Wichita, Kan.