In skilled nursing facilities, a more
personal approach to patient care is proving rewarding to RCPs.

“I never dreamed that I would ever be working in long-term care–or that I would be enjoying it as much as I am,” says Steven Hall, RRT, lead respiratory therapist at Woodmill Rehabilitation and Nursing Center in Lawrence, Mass. Much to his surprise, Hall, who previously worked in an acute care hospital, has discovered he truly loves interacting with nursing home patients. He has also discovered abundant opportunities for professional development. These days, he believes an RCP can often achieve more growth in a skilled nursing facility (SNF) than in a hospital setting.

Making A Difference

Hall believes an SNF is a place where an RCP can make a major difference, to both patients and staff. To illustrate his point, he talks about an early experience on the job: “I had been here for only 2 weeks when one of the nurses called to say a resident was going into respiratory failure,” he says. “I didn’t know where all the equipment was kept, but I grabbed an ambu bag and whatever else I could find, and I rushed to the room. The patient appeared not to be breathing. I began assessing her and listening for breath sounds, and when I tried to arouse her, she opened her eyes and began to breathe spontaneously. So I backed off and just kept the ambu over her, letting the oxygen flow over her mouth. I kept the oximeter on and waited while her sats climbed. Her oxygen saturation started out at 72% I let it get up to 977before I took the oxygen off. Then I just stayed with her until the paramedics arrived to take her to the hospital. The nurse was in the room with us doing vital signs, and she kept saying how glad she was that I was available.”

This kind of situation arises frequently in SNFs, where patients generally are elderly and there is not always a physician in the building, Hall says. Until recently, RCPs were rarely in the building, either. This is changing, however, according to Leopold Dirlinger, RRT, manager of respiratory care at Briarwood Healthcare Nursing Center, a Vencor facility, in Needham, Mass. “Until the early 1990s, nursing homes followed the traditional concept. They had floors where residents were active, playing cards and attending movies. On other floors were very sick people receiving care from nurses and aides,” Dirlinger says. First, with prospective payment, then, with managed care, hospitals began sending patients to rehabilitation or SNFs as soon as any acute surgical or medical intervention was completed.

“The SNFs were well positioned to accept these patients because they provided a relatively less expensive placement than a hospital,” Dirlinger says. To meet the needs of these new patients, many SNFs found they needed to expand their services. “While hospitals were seeing less need for allied health professionals and reducing FTEs [full-time employees], skilled nursing facilities were looking at allied health and adding programs,” Dirlinger says.

Prominent among these was respiratory care. For example, Dirlinger’s facility has piped one unit with liquid oxygen and now accepts ventilator-dependent patients who have failed to wean in the hospital. The facility also admits patients with long-standing pulmonary problems who need workups and offers pulmonary rehabilitation to patients with chronic obstructive pulmonary disease (COPD). In addition, Briarwood cares for many tracheotomized patients, helping them reach the point where they can be decannulated and go home, Dirlinger says. “I think a case can be made that patients do much better in a nonhospital environment once their condition has been stabilized and they can concentrate on the pulmonary aspects,” he says.

A Peaceful Environment

“As soon as you come in, you realize that it is a much quieter environment than a hospital,” Dirlinger says. “Demands are put on the client by PTs [physical therapists] and OTs [occupational therapists], but it is a much friendlier milieu. On the rehab unit, therapy goes on 6 days a week, so clients know that the staff are committed to progress. And the numbers are smaller–just 35 beds,” Dirlinger says.

He estimates that 505to 60 of the patients eventually go home. “One man has been here for over a year, and now he is ready to take his own apartment,” Dirlinger says. He wonders, however, what happens to people who do not have this opportunity for extended therapy. “These are people who would have fallen through the cracks,” he points out.

A good illustration is ventilator patients who have failed to wean in the hospital. “When we say patients fail to wean, it implies that due to either acid-base imbalance or to anxiety, they have not been able to remain off the ventilator,” Dirlinger says. Sometimes the underlying cause is simply poor nutritional status and general debilitation, but in many instances, there are specific medical conditions that have not been resolved. “It can be diabetes or other metabolic problems, ulcers, stress–you have to get the whole body regulated. When people are fatigued or exhausted or overwhelmed, breathing is the first thing that is affected. And under the prospective payment system, staff in the hospital have no patience when people fail to wean. People fall through the cracks because the hospital wants to get them out so fast,” Dirlinger says.

Dirlinger believes SNFs are able to accomplish so much because they have more time for patients and are smaller than hospitals, and because they have a highly interdisciplinary approach. “In a small environment, the emphasis is on assessment,” he says. Therapists in each discipline evaluate patients as soon as they arrive at the facility and a plan of care is put together rapidly. Then, to ensure progress, respiratory, PT, OT, speech, and the other disciplines meet frequently. “Everyone has to meet at least twice a week and everyone has to be there. And to meet, you have to assess the patient. One reason there is so little assessment in large hospitals is that nobody talks to one another,” Dirlinger says.

According to Jane McKay, RRT, regional continuous quality improvement (CQI) manager for SunCare Respiratory Services, in Stratford, Conn, a company that contracts to provide respiratory therapy in SNFs, therapists in a hospital often come into a patient’s room simply to do a task. “They are not part of the team. They are not invited to care planning meetings, they are not invited to discharge planning meetings, all the things that enhance the care of the patient,” McKay says. She believes many patients require a more holistic approach, and many times that can be done more effectively in an SNF than in the hospital, she says.

McKay’s company assigns a lead therapist to each SNF who is present 5 days a week. “This is really essential because care in an SNF is all about relationships,” McKay says. Therapists in SNFs not only form relationships with their patients, but they have ongoing relationships with families, therapists in other disciplines, administration, physicians, and especially nurses.

“In the past few years, nursing staff have been asked to take care of more critically ill patients. They welcome having somebody on hand who understands how to take care of a tracheotomized patient, who understands CPAP [continuous positive airway pressure],” McKay says. At the other end of the spectrum of acuity, McKay says that the nurses often ask RCPs for a second opinion on routine assessments–for example, “When you listen to this patient’s lungs, do you hear what I hear?” McKay says.

Common diagnoses in SNF patients include pneumonia and COPD, but quite a few patients have nonpulmonary diagnoses as well, McKay says. These are patients who require breathing retraining after becoming deconditioned during a long hospitalization. “We teach them effective breathing techniques and work closely with PT, OT, and speech while these patients are regaining strength and mobility,” McKay says.

Her therapists report success with tracheotomy patients, weaning them to decannulation. They also see patients who have sleep apnea. “Usually those patients come to us already diagnosed and we do a lot of education with them and with their families. We can also do titration in this setting,” McKay says.

SunCare therapists measure blood gases when necessary and provide such basics as bronchodilator therapy, metered-dose inhaler (MDI) instruction, and chest physiotherapy. “We also do some very basic pulmonary function testing, using a bed-side spirometer,” McKay says. Some facilities serve as clinical sites for respiratory therapists in training. “Skilled nursing is a good setting for first-year students who are learning how to assess a patient, look through a chart, and communicate with a physician,” McKay says.

A Two-Way Street

“A lot of therapists really love this environment. They can come out of the hospital–where they were just reacting to a beeper–and actually build a program,” McKay says. Their role includes hands-on care, case planning, some administrative work, and in-servicing with nurses. Learning is a two-way street. Because RCPs work so closely with people in other disciplines in the skilled nursing setting, they can learn a great deal about what those disciplines do. “I worked in a hospital for many years, and I can’t tell you the name of one physical therapist I worked with. They came and took my patient down to the gym, and I never knew what they did,” McKay says.

In SNFs, RCPs also play an active part
in negotiating with case managers. “Sometimes we end up calling them directly or faxing them. Decisions get made within hours as to how much money is going to be allocated for a particular patient. So sometimes, we may fax our evaluation form or other information to establish what we found clinically and for how long we believe we need to see the patient,” McKay says.


Most patients are covered by Medicare. Meticulous documentation is required from RCPs to ensure the facility receives full reimbursement, McKay says. The prospective payment system is currently being restructured, with reimbursement for respiratory therapy being phased into the routine costs instead of being part of the ancillary costs.

“SNFs will receive a certain amount of money based on the resource utilization group [RUG] group the patient is placed in based on a clinical assessment,” McKay says. According to McKay, since the recent change in prospective payment was implement, respiratory therapy has had to prove its clinical value all over again.

According to Janet Chlapeka, CRTT, PSGT, respiratory care manager for Chartwell Midwest, in Bethany, Ill, although many SNFs contract for respiratory therapy, a growing number have decided to employ therapists directly. “This depends upon payor mix,” Chlapeka says. “More and more patients are under managed care, including many Medicare beneficiaries who are joining senior HMOs.”

As Chlapeka points out, shifting to prospective payment in one part of the health care system may have large, sometimes unforeseen, consequences elsewhere. “We’ve already seen this in skilled nursing facilities. When hospitals went under the Medicare DRGs [diagnosis related groups], they started discharging patients much sooner, and this caused growth in home care and skilled nursing facilities,” Chlapeka says. In the 15 years since the DRGs were first implemented in hospitals, many SNFs have opened rehabilitation units or subacute floors, Chlapeka says. Payment for care under these programs is tightly managed, so many nursing homes have learned how to package their highly interdisciplinary service and deliver it economically.

McKay notes that subacute care is accredited separately under JCAHO, with a focus on an interdisciplinary approach to treatment. “They want to make sure that any change in patient condition is communicated to everyone involved in the patient care team,” McKay says. Subacute accreditation also requires extensive documentation of competencies. “There has to be evidence that staff have received training in assessment for specific conditions and that they have training in specialized equipment–for example, in CPAP and BiPAP [bilevel positive airway pressure] systems,” McKay says.

“I have noticed since I started working in long-term care that we admit a lot more patients for subacute care or rehabilitation,” Hall says. “Not as many as you would see in a rehabilitation hospital, but we see many people who are here for a 6- or 8-week stay.” Whether an RCP is working on the subacute side or the skilled nursing side of a facility, Hall believes the interdisciplinary focus prevails.

In addition to short-term patients, his facility has many clients living there permanently. Many of these patients seem to develop respiratory problems, especially recurring pneumonias and COPD. “The benefit of having respiratory therapy on board is that the nurses do not feel they need to send these patients out to an acute care facility right away,” Hall says. “We can implement supplemental care, such as nebulizer therapy, to ease their work of breathing while they are getting antibiotic therapy, and give them a greater degree of comfort while they are going through the healing process,” Hall says. “Often, we hear something in the breath sounds and tell the nurse that we think something is brewing. We suggest asking the physician to order a chest x-ray to take a closer look before this becomes a major problem,” Hall says.

In acute situations, he finds that RCPs are able to quickly assemble the correct supplies and exercise certain judgment skills more confidently than the nurses. “For example, in the case of someone with an exacerbation of COPD–certainly a respiratory arrest–or in the case of someone with a very high respiratory rate or shallow breathing, we recognize the direction they are headed in and we know it is not good,” Hall says. “Being able to intercept a problem before it becomes a crisis is also very important, and we are available to do that.”

India Smith is a contributing writer for RT.