The Value of the Respiratory Therapist Delivering Respiratory Care

Transcription

1 The Value of the Respiratory Therapist Delivering Respiratory Care Tom Lamphere BS, RRT-ACCS, RPFT, FAARC Executive Director, Pennsylvania Society for Respiratory Care Instructor, Resp. Care Program Gwynedd Mercy University Staff Therapist, Grand View Hospital Sellersville, PA

2 Definition of Value A fair return or equivalent in goods, services, or money for something exchanged The price or cost of something (monetary worth) Usefulness or importance

3 How Is Value Determined? Some things can be considered valuable and have virtually no monetary value for example pictures of one s children, a memento from many years ago, etc.. For goods and services, value is determined by the buyer, not the seller! While you may view a good or service as being valuable, if you don t have a buyer that views it that way, how valuable is it?

4 How Much Value? Not much.. A whole lot!!!

5 How Much Value? Lots especially in the morning! Eh..not so much.

6 How Much Value? Lots of value!

7 How Much Value? Not So Much..

8 What s Valuable to a Hospital? Definition of what is valuable has been constantly changing over the past 25 years. In 1970s & early 1980s, insurers (both private and Medicare) reimbursed hospitals for pretty much everything equipment, supplies, services. Hospitals were well staffed as the reimbursements were high.

9 What s Valuable to a Hospital? 40 neb treatments, 10 ABGs and 15 IS txs. Administration is going to love us this month! Respiratory Care departments valuable as they were the largest revenue center for many hospitals. The more treatments and procedures that were done, the more revenue hospitals received.

10 What s Valuable to a Hospital? Diagnosis-Related Group (DRG) were imposed on hospitals nationwide for Medicare patients DRGs shifted the payment system for pay for each individual item to a lump sum payment based on a patient s diagnosis forcing hospitals to change how they approached patient care with a focus on getting patients out of the hospital faster. If a DRG payment for a patient with COPD was $4,000, the only way a hospital could make a profit was to care for the patient at a cost less than that amount. Therefore, the sooner the patient was discharged, the more likely a profit was seen.

11 What s Valuable to a Hospital? Respiratory Care department quickly switched from the largest Revenue Center to the largest Cost Center due to it s high use of equipment and supplies and the value of the RT diminished. Increased focus by hospital administrators on equipment, supply costs, personnel costs. Patient Focused Care models began to appear essentially wiping out RT departments. These models failed and departments returned.

12 Changes Brought On By New Reimbursement System 1990 Respiratory Care Manager Office 2011 Respiratory Care Manager Office

13 Healthcare Challenges in 2015 & Beyond Current US healthcare model is unsustainable. In 2013, the U.S. spent 2.9 trillion $9,255 per person which represents 17.4% of the Gross Domestic Product and it s growing. This cannot be sustained due to the aging of the Baby Boomer generation. In 2010, 40 million Americans were age 65 or older. By 2030, that will grow to 71.5 million. Age 65 and up account for 26% of MD office visits, 35% of hospital stays, 34% of Rx, 38% of Emergency calls.

14 Affordable Care Act Medicare rules are changing quickly! Two major changes (out of many) that have a big effect on Respiratory Therapists include: 1. Value Based Purchasing Day Readmissions

15 Value Based Purchasing What Is It? Program that went into effect on October 1, 2012 to reward hospitals for high-quality, safe care for patients Hospitals paid for better value, patient outcomes, and innovations, not volume of services Think of it as a hospital report card: Get good grades, get rewarded with more $ Incentive payments based on two factors How well hospitals perform compared to other hospitals nationally How well internal hospital performance improves relative to baseline period Key measures include clinical outcomes, patient experience, efficiency, and care coordination In other words, Medicare is going to get value for its money. ACA calls for extending this program to other providers such as SNFs, HHAs, and physicians

16 Value Based Purchasing How Does it Work? Funding pool for incentive payments comes from hospitals base DRG payments Tracks quality measures related to common & high cost conditions 1% in FY 2013; 1.25% in FY 2014; 1.5% in FY 2015; 1.75% in % in FY 2017 and subsequent years FY 13 heart attack, heart failure, pneumonia, surgical care and hospitalacquired conditions FY day mortality for heart attack, heart failure and pneumonia was added Clinical pneumonia measures tracked Blood cultures performed in ED prior to initial antibiotic received in hospital Initial antibiotic selection for CAP in the immunocompomised patient

17 Value Based Purchasing How Does it Work? Patient Experience of Care Nurse Communication Physician Communication Hospital Staff Responsiveness Pain Management Medication Communication Hospital Cleanliness & Quietness Discharge Information Overall Hospital rating

18 Cost of Readmission 17.6% of Medicare patients readmitted to hospitals within 30 days of discharge 75% of all Medicare readmissions are identified as avoidable Annual cost of readmissions to Medicare is $26 billion of which it is estimated that $17.5 billion could be eliminated if the patients received the right care.

19 Cost of Readmission Reduces payments to hospitals that have excess readmissions w/in 30 days of discharge 1% maximum penalty of TOTAL Medicare payments in first year Three diagnoses tracked in FY 2103: Heart attack, heart failure, and pneumonia Data to be reported on CMS Hospital Compare website Effective October 1, 2012 (FY 2013) Increased to 2% in FY 2014 and 3% in FY 2015 and beyond COPD was added in

20 Hospital Acquired Conditions (HAC) Medicare now assessing penalties for HACs including: Pressure ulcer Iatrogenic pneumothorax Central venous catheter-related blood stream infection Postoperative hip fracture Postoperative pulmonary embolism (PE) or deep vein thrombosis (DVT) Postoperative sepsis Wound dehiscence rate Accidental puncture and laceration

21 Hospital Acquired Conditions (HAC) More being added to the list in 2015 and beyond including: Surgical site infections (October, 2015) C-Diff MRSA Hospitals that fall in the top 25% in terms of frequency receive a 1% reduction in payment

22 ACA Penalties & Bonuses: What Do They Mean in REAL $$? Example 1: Grand View Hospital, Sellersville, PA Received approximately $12,000,000 in payments from Medicare for top 63 DRGs (2012 data). Value-Based Purchasing and Readmission Bonus/Penalty for 2014 was 0.62% This means the hospital received a BONUS payment of 0.62% or $74,000 from Medicare.

23 ACA Penalties & Bonuses: What Do They Mean in REAL $$? Example 2: Allegheny General Hospital, Pittsburgh, PA Received approximately $36,300,000 in payments from Medicare for top 100 DRGs (2012 data). Value-Based Purchasing and Readmission Bonus/Penalty for 2014 was -0.47% This means the hospital will receive $170,610 LESS than their normal payment from Medicare

24 ACA Penalties & Bonuses: What Do They Mean in REAL $$? Example 3: Mercy Medical Ctr, Des Moines, IA Received approximately $63,047,000 in payments from Medicare for top 98 DRGs (2012 data). Value-Based Purchasing and Readmission Bonus/Penalty for 2014 was 0%. If the hospital has just a 1.0% penalty, the hospital would receive $630,470 LESS than their normal payment from Medicare

25 Will There Be A Need For Respiratory Care? Despite all the advancements in mechanical ventilation, pharmacology and other treatment modalities, there will be a need for someone to deliver respiratory care to patients. The quality of the care (i.e. evidence-based therapy) will improve. The question is not IF there will be a need but, rather, WHO will deliver that care!

26 Can Respiratory Therapists Demonstrate Value By Providing Knowledge & Skills Others Cannot Provide? Average RT believes most everything they do cannot be done by others. In many areas of U.S., other healthcare workers (RN, Paramedics, LPN) can legally provide procedures typically done by RT. The main categories of care provided by RTs include: Oxygen Therapy, Aerosol Delivery, Mechanical Ventilation, Bronchial Hygiene, Patient Education

27 Can An RN Perform All of the Functions of A Respiratory Therapist? Multiple ways to interpret & answer the question Is it Legal? In nearly all states, RNs can legally perform all the functions of a respiratory therapist with no additional training or credentialing. This includes arterial blood gas sampling, mechanical ventilation, aerosol therapy, etc.. However, they must demonstrate continuing competency on any functions they do perform.

28 Are RNs Educated in Respiratory Care Modalities? Basic science & math course requirements are virtually identical (A&P, Microbiology, etc..) Most programs include very basic instruction on ABG interpretation, oxygen therapy, aerosol therapy. Very little if any training on equipment beyond the basic instruction and use of device. Instruction on pharmacology, hemodynamics, patient assessment and patient education is at or above the level of many RT programs.

29 Study Finds Respiratory Care Instruction Very Limited In Nursing Schools Robert Czachowski, PhD Study conducted in by the Indiana University Center for Survey Research 617 nursing programs and 223 respiratory programs participated. Study consisted of a survey evaluating and comparing the curriculum of the participating programs in 15 typical respiratory care procedures.

30 Study Finds Respiratory Care Instruction Very Limited In Nursing Schools Summary of Results The findings of this study suggest that the entry-level registered nurse, regardless of the source of education, will have had extremely limited didactic instruction in the 15 typical respiratory therapy procedures included in this survey. Clinical exposure of nursing students to respiratory procedures may or may not occur, depending on patient availability.

31 Study Finds Respiratory Care Instruction Very Limited In Nursing Schools

32 Study Finds Respiratory Care Instruction Very Limited In Nursing Schools

33 Study Finds Respiratory Care Instruction Very Limited In Nursing Schools

34 Study Finds Respiratory Care Instruction Very Limited In Nursing Schools

35 Study Finds Respiratory Care Instruction Very Limited In Nursing Schools Comments From RN Programs "Not at this time-no time to fit it in. "Nursing education related to respiratory therapy is based on the clients and their responses or needs. It is, therefore, more theoretical vs technological "We usually have a respiratory therapist come in and do a two-hour class for us" "Not expected to function as respiratory therapists. Complex therapies."

36 Nurses Knowledge of Inhaler Technique in the Inpatient Hospital Setting Study of 100 nurses conducted at a 495 bed urban academic medical center in Midwest U.S. Participants demonstrated inhaler technique to the investigators using both a metered dose inhaler (MDI) and Diskus device inhaler, and performance was measured via a validated checklist. Findings: Overall misuse rates were high for both MDI and Diskus devices. There was poor correlation between perceived ability and investigator-measured performance of inhaler technique. Clinical Nurse Specialist. Issue: Volume 28(3), May/June 2014, p

37 Medical Personnel s Knowledge of and Ability to Use Inhaling Devices (MDI, Spacing Chambers & Breath-actuated Dry Powder Inhalers Study of 30 nurses, 30 RTs and 30 MDs conducted at tertiary care university-based hospital. CHEST. 105 / 1 / January, 1994

38 Do Respiratory Therapists Have Unique Knowledge & Skills Others Do Not? Oxygen Therapy Aerosol Delivery Mechanical Ventilation Bronchial Hygiene Therapy Patient Education NURSE TRAINING Importance of O2 and basic training in O2 devices. Basic training of nebulizers and MDI as well as Resp. medications Very basic training of theory of mechanical ventilation incl. basic modes (A/C, SIMV, CPAP, PEEP) Basic to Intermediate training in use of Incentive Spirometry and cough Advanced training in all areas of patient education incl. social aspects RESP. THERAPIST TRAINING Advanced training in both theory & O2 devices. Advanced training in all aerosol delivery devices (Neb, MDI, DPI, Mesh-Type) and meds Advanced training in all forms (invasive, non-invasive modes of mechanical ventilation in addition to all modes of ventilation Advanced training in all forms of bronchial hygiene including I.S., PEP therapy, Chest PT, suctioning Basic to Intermediate training in patient education for respiratory related therapies.

39 1. Education & Credentials CRT credential is minimum requirement for a license but RRT credential demonstrates advanced education. AS degree is currently entry level requirement bare minimum. BS degree will eventually be entry level and is already being sought by employers when deciding among applicants. CRT is nice; RRT is great but there ARE other credentials including ACCS, NPS, CPFT, RPFT, & SDS

40 2. Protocols, Best Practice & Evidence-Based Medicine No longer optional multiple studies have demonstrated misallocation of respiratory care at rates of 20-50%. This must be reduced to 0% as this therapy increases costs with absolutely no benefit to the patient. Very few RT departments utilize protocols for 100% of the care delivered. Most use some protocols but as many as 40% do not utilize bronchodilator and/or ventilator protocols. There is ample research demonstrating the benefit of protocol usage.

41 3. The Right Equipment Must Be Utilized Many facilities continue to utilize nebulizers that deliver virtually no aerosol particles in the respirable size because the devices are cheap to purchase. Non-invasive ventilation masks continue to be utilized despite the fact that their routine use leads to skinbreakdown, patient non-compliance or lack of ability to utilize all of the BiPAP or CPAP unit s capabilities

42 4. RTs Must Be EXPERTS In Respiratory Equipment An RT must know every control and function of the equipment they utilize for patient care. If not, they will be replaced by one that does. Examples include mechanical ventilator modes and settings (including APRV, ASV, etc.), BiPAP controls (Ramp, C-Flex, Rise Time, etc.) and new aerosol devices (Aerogen, Respirmat inhaler, etc).

43 5. RTs Must Be EXPERTS In Respiratory Pharmacology RTs must be familiar with more than just Albuterol, Atrovent, Advair and Symbicort. New medications such as Breo Ellipta, Anoro Ellipta, and Brovana are being released VERY frequently and it s the RT s responsibility to stay on top of them. The RT must know the type of drug, dosages, frequencies, indications, contraindications, proper administration technique and more.

44 6. RTs Must Be EXPERTS In Cardio-Pulmonary Pathophysiology How can an RT recommend a therapeutic option to a physician if they don t know the pathophysiology of the patient s disease? How can a therapy be evaluated for effectiveness without this knowledge?

45 7. RTs Must Become Disease Managers COPD, Asthma and other chronic conditions are a big part of the ACA and an RT s knowledge of these conditions make them prime candidates to lead initiatives to improve the care of these patients to reduce both length of stay and readmission rates.

46 8. RTs Must Be GREAT Patient Educators Handing a patient instructions or giving them the bare bones verbal instructions for a particular RT procedure is no longer acceptable. This can lead to increased patient readmissions and/or poor patient satisfaction scores which can cause a reduction Medicare reimbursement.

47 9. RTs Must Communicate With Physicians, Nurses and Other Members of the Healthcare Team An RT who cannot effectively communicate with physicians and other healthcare team members will soon find that they are no longer part of the team and subsequently no longer employed. RTs must be constantly looking for ways to improve the patient s condition by recommending and/or implementing the most effective therapy possible.

48 If nobody is asking your opinion, you probably don t matter. Robert Kacmarek PhD, RRT, FAARC

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50 Thank You! Tom Lamphere BS, RRT-ACCS, RPFT, FAARC