44th Annual Conference & Exhibition July 9-11, 2015 Houston TX. Respiratory Care : A New Profession is Evolving

Transcription

1 44th Annual Conference & Exhibition July 9-11, 2015 Houston TX Respiratory Care : A New Profession is Evolving Patrick J. Dunne, MEd, RRT, FAARC HealthCare Productions, Inc. Fullerton, CA pjdunne@sbcglobal.net

2 Disclosure Professional relationship with Monaghan Medical Corporation Mylan Pharmaceutical Career-long member/supporter of AARC State affiliates Texas Society

3 Objectives Review the government changes in health care replacing the traditional FFS delivery of care model; List those instances where government change will directly influence the delivery of respiratory care; Describe the key features of the emerging chronic care model and how RTs can become actively involved, and Identify a high-value contribution that RTs can make to improve patient safety.

4 Situational Analysis Summer 2015 Health care reform s operative buzz words Disruptive change, Transformational change, Game changer, Disruptive innovation, Radical redesign, Fundamental shift, etc. Bottom line - - It s system wide All providers eventually affected Patient Protection and Affordable Care Act of years & still going strong In spite of set-backs with exchanges, subsidies, etc. Millions of Americans realizing positive benefits 2 more years of continued implementation Elections of 2016 Some may campaign on complete repeal Given evidence Repeal no longer a realistic option

5 Government Change in Health Care Sleepless in the C Suites MAJOR ONGOING ORGANIZATIONAL CHALLENGES Transition to EHR Hospital Compare website Physician Compare website Experience of Care impact Inconsistent hospital rankings Newer Joint Commission expectations Transition to ICD-10 coding

6 Angst in the C Suites Revenue Stream Challenges Value-based Purchasing Effective FY 2012 FY 2015: Up to 1.5% bonus (or) penalty 30% of all payment by 2016; 50% by 2018 Hospital Readmission Reduction Program (up to 3% penalty) Effective FY 2012 FY 2015: $429 million from 2,610 hospitals Hospital-acquired Conditions Reduction Program (1% penalty) FY 2015: $330 million from 724 hospitals nationwide Post-op pulmonary conditions (PPCs) a major concern

7 Government Change in Health Care The New Environment of Care TRADITIONAL EMPHASIS Acute care In-patient Treat symptoms Billable procedures Individual patient Volume metrics NEWER EMPHASIS Chronic care Out-patient Manage disease Outcomes of care Patient populations Value metrics It s no longer about how many or what kind of procedures are done... It s all about HOW care is delivered!!

8 Challenges to Respiratory Care Services Traditional Role Changing Consultants abound Contingency-based fee Others can do basic RT treatments True value not always obvious Making crisis moments look routine Traditional productivity metrics no longer relevant Linkage to billable procedures very limiting Transition to relative value units (RVUs) Capture clinical productivity in all areas for all activities Full integration into EHR

9 Challenges for Respiratory Care A Defining Moment in our History Adapt or become irrelevant Maintaining status quo risky Conventional wisdom sometimes iffy Seize/embrace new opportunities Align with main concerns of the C-Suites Be perceived as part of the solution Talk the talk & walk the walk of health care reform It s really payment reform!!! Maintain/strengthen existing clinical competencies Change context in which we practice Referral vs. an order Care vs. treatments Service vs. a department

10 The AARC Response Strategic Plan Embodies key recommendations of 2015 and Beyond initiative Formally approved October 2014 Eight major objectives Each objective fully described Implementation strategies identified Facilitate orderly, well-planned transition Involve all key stakeholders Minimal disruption to existing workforce

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12 The AARC Response Strategic Plan Objective 1. Refine and expand scope of practice Promote advanced practice for RTs, inclusive of scientific evidence demonstrating the value/role of RT in all practice settings; Advocate clinical practice to be outcome-based, value-driven and delivered using evidence-based protocols Expansion to encompass: Advanced practice credentialing, Chronic disease management, Health/wellness educator, Telehealth, and others.... Services that emphasize quality, access, and cost savings unique to RT;

13 The AARC Response Strategic Plan Objective 2. Advance knowledge base/educational preparation of RTs Support existing & future articulation agreements between associate and bachelor degree programs; Expedite development of bachelor/graduate degree programs with goal of BS as entry level; Work with state affiliates/licensing boards to establish RRT credential as entry-level for licensure.

14 The AARC Response Strategic Plan What about here and now? How about the 140,000-plus RTs nationwide?

15 Challenges for Respiratory Care A Defining Moment in our History Advocate for better chronic care Develop a chronic care footprint MacColl Institute Participate in care transition Become patient safety advocate Improve/formalize all patient handoffs Adopt patient safety checklists Monitor Patient Safety Roundtable (AARC Connect) Address post-operative pulmonary complications

16 Impact of of Chronic Conditions Chronic conditions overly expensive Account for ⅔ of total expenditures ($1.8 of $2.8 trillion) Most characterized by frequent exacerbations Excessive hospital utilization Symptom treatment versus disease management Current sense: Traditional chronic care is ineffective Multiple providers = fragmented care = uncoordinated care Information not shared (set-backs, complications, changes) Evidenced based care the exception, not the rule

17 Chronic Disease Management A Global Problem

18 Chronic Disease Management Coordinated approach to chronic medical care Improve health outcomes, quality of life Reduce disease progression, complications Manage health care utilization Traditional payment model broken New payment models per 2010 PPACA Act Hospital readmission reduction program Value based purchasing Accountable care organizations Patient centered medical homes The evidence: Community-based programs work

19 The Chronic Care Model MacColl Institute

20 Patient Safety: The Early Days Published 1999 by US Institute of Medicine Based on Harvard Medical Practice Study (N Engl J Med; 1991) Estimated 44,000 to 98,000 preventable deaths each year Error rate highest in Intensive/critical care units, Surgical suites, Emergency departments

21 Patient Safety: Today Journal of Patient Safety Vol 9; No 3: September 2013 Literature search ,000 to 400,000 preventable deaths per year Non-lethal harm 10-to-20 fold higher Near misses/non-reported incidents unknown

22 AARC Resources

23 AARC Patient Safety Checklists In-Hospital Oxygen Transport

24 AARC Checklists Transfer from Intensive care

25 Post-operative Pulmonary Complications (PPCs) Major patient safety implications Relatively recent area of investigation Prevalence following general surgery/anesthesia Overall range: 2% to 40% 2% (low risk pt. & low risk procedure) 40% (high risk pt. & high risk procedure) 10-fold higher mortality in abdominal pts. Risk intensifies closer to diaphragm

26 PPCs (cont.) Increases LOS 12 days vs. 3 days Increases 30-day readmissions Major contributor to surgical morbidity, mortality & costs A marker for high mortality in hospitalized elderly pts.?

27 Surg Clinics N Amer. Volume 95; April 2015

28 Surg Clinics N Am. Volume 95: April 2015 PPCs are more of a financial burden than cardiovascular or infectious complications after surgery, costing the US $3.4 billion annually

29 Major PPC Conditions Atelectasis Respiratory infection (fever) Bronchospasm Aspiration pneumonia Pleural effusion Pneumothorax Respiratory failure

30 Predictive Factors for PPCs Smetana GW. Ann Intern Med Patient Related Age ( 65 yrs.) Low SpO 2 ( 90%) Recent respiratory infection (2-3 weeks) Anemia Procedure Related Surgical site/procedure (Cardio-thoracic, abdominal) Length of surgery ( 2.5 hrs.) Emergency vs. elective

31 Additional Risk Factors for PPCs Branson R. Respir Care; November 2013 COPD CHF OSA (esp. undiagnosed/untreated) Other chronic conditions (i.e. diabetes) Cigarette smoker Functional dependence Impaired sensorium Drug/alcohol dependence

32 Pulmonary Effects of General Anesthesia Including Endotracheal Intubation Mechanical disruption to delicate muco-ciliary escalator Contributes to retained secretions Bronchoconstriction due to release of circulating mediators Lungs normal response to inhaled noxious gases Decrease of surfactant production Undermines stability of alveoli Inhibition of alveolar macrophages Dust cells unable to scavenge

33 Excess Airway Mucus linked to PPCs Increased Production Current smokers History of COPD Congestive heart failure Viral/bacterial infection Excess Decreased cough mucus Poor pain control Poor ciliary function Impaired diaphragm function Airway occlusion/atelectasis Resp. muscle weakness Decreased Elimination Increased risk of Postoperative Pulmonary Complications

34 Role for OPEP Therapy in PPCs? Recent Studies Postoperative OPEP in thoracic & upper abdominal surgery patients 1 Decreased risk of fever (statistically and clinically relevant) 2.6 day shorter hospital stays Well tolerated and accepted by patients with no adverse events PEP in postoperative coronary artery bypass graft (CABG) patients 2 Reduced rates of pulmonary complications (pneumonia) Improved pulmonary function Better 6 minute walk distances 1. Zhang X, Wang Q, et al. Journal of Physiotherapy Haeffener MP, Ferreira GM, et al. American Heart Journal; Nov 2008

35 Summary The Dawning of a New Era RT Departments MUST re-design traditional operations to compete in new environment of care realities: Align current practice with newer expectations Hospital s responsibility no longer ends at discharge Poorly treated chronic patients a huge financial liability Explore alternative post-discharge follow-up options Improving chronic care outcomes a new priority Make evidence-based care the rule, not the exception Advocate for protocol/algorithm directed practice Undertake value-analysis to eliminate low-value activities Explore high-value opportunities

36 44th Annual Conference & Exhibition July 9-11, 2015 Houston TX Respiratory Care : A New Profession is Evolving Patrick J. Dunne, MEd, RRT, FAARC HealthCare Productions, Inc. Fullerton, CA pjdunne@sbcglobal.net