Respiratory Care 2015: What Does The Future Hold? Timothy R. Myers MBA, RRT-NPS Director, Women s & Children s Respiratory Care & Procedural Services and Pediatric Heart Center Rainbow Babies & Children s & MacDonald Hospital for Women Adjunct Faculty, Assistant Professor Department of Pediatrics, Case Western Reserve University Cleveland, Oh The Target of an Organization AARC Vision and Mission Statement The American Association for Respiratory Care (AARC) will continue to be the leading national and international professional association for respiratory care. The AARC will encourage and promote professional excellence, advance the science and practice of respiratory care, and serve as an advocate for patients, their families, the public, the profession and the respiratory therapist. 3 1
When you change the way you look at things, the things you look at change. Heisenberg Uncertainty Principle 4 2015 and Beyond AARC Leadership has initiated a threeseries conference to define the role of the RCP in light of future healthcare trends and to determine an effective strategy for achieving success as a profession based on the needs of the respiratory care patient and the evolving health care system 5 2
Preview The first task force conference affirmed that the healthcare system is in the process of dramatic change, driven by the need to improve health while decreasing costs and improving quality. This will be facilitated by application of evidence-based care, prevention and management of disease, and closely integrated interdisciplinary care teams. The second task force conference identified specific competencies needed to assure safe and effective execution of RT roles and responsibilities in the future. The third task force conference was charged with creating plans to change the professional education process so that RTs are able to achieve the needed skills, attitudes, and competencies identified in the previous conferences. The Mission The Charge To determine the changes required by the profession of respiratory care to meet the evolving demands of the medical community and to position respiratory therapists (RTs) as a vital member of the medical community in 2015 and beyond 3
The Questions How will patients receive healthcare services in the future? How will respiratory therapy be provided? What knowledge, skills, and attributes will RTs need to provide care safely, efficiently, and costeffectively? What education and credentialing systems are needed to provide this knowledge and these skills and attributes? How do we get from the present to the future with minimal impact on the respiratory therapy workforce? Attributes That 2015 Transition Plans Must Meet 1. Maintain an adequate respiratory therapist workforce throughout the transition. 2. Address unintended consequences such as respiratory therapist shortages. 3. Require multiple options and flexibility in educating both students and existing workforce. 4. Require competency documentation options for both new graduates. 5. Support a process of competency documentation for the existing workforce. 4
Attributes That 2015 Transition Plans Must Meet 6. Assure that credentialing and licensure recommendations evolve with changes in practice. 7. Address implications of changes in licensing, credentialing and accreditation. 8. Establish practical timelines for recommended actions. 9. Assure that emerging conference recommendations must be supported by a plurality of the stakeholders in attendance. Attributes That 2015 Transition Plans Must Meet 10.Reflect the outcomes of the previous two 2015 and Beyond conferences 11.Identify the agencies most appropriate to implement identified elements. All attributes were accepted by AARC Bod except: Assure that emerging conference recommendations must be supported by a plurality of the stakeholders in attendance. 5
1 st Consensus Conference: Dallas, Texas March 2008 12 Conference One Held in Dallas, Texas, on March 3 5, 2008 co-chaired by John Walton and Dr. Charles Durbin Stakeholders invited with 35 conference participants At the conclusion of the conference, a lengthy discussion by all attendees created a preliminary outline of the conference s findings. Conference summary refined by the task force and sent to all attendees for review and comment Based on attendee feedback, a final conference summary was developed, approved by the planning committee and sent to all conference participants 13 6
Predicted Changes in Health Care United States population continues to age with more chronic and acute respiratory diseases being diagnosed Increased accuracy of diagnosis Treatment aimed at outpatient management and hospital admission avoidance Increasing numbers of co-morbid conditions that will require management / treatment Health promotion will become the goal of care 14 Predicted Changes in Health Care Cost increases for care will continue with increasingly difficulty to meet these expenses Personal electronic health records will be more widely accepted and used in all care settings Health-care consumers will pay a greater percentage of costs Retail health clinics and other mass-marketed care centers will stimulate consumer-driven cost competition 15 7
Predicted Changes in Health Care Hospitals will provide expensive, episodic care and house cutting-edge respiratory life-support technology Subacute and home care providers will continue to play important roles delivery of acute care will move progressively to the patient s home Subacute and chronic care will increase in volume and complexity 16 Predicted Changes in Health Care Increased complexity of care will heighten the need for better communication: among all care providers between the patient and family members Medical care will undergo: increasing scrutiny for quality linked quality to reimbursement Include initiatives such as pay-for-performance Reimbursement and costs will influence the development and success of these new models 17 8
Changes Expected in Respiratory Care Science of respiratory care will continue to evolve and increase in complexity Clinical decisions will become increasingly data-driven Respiratory care will be an important part of care in all venues Evidence-based algorithms (protocols) will be most common way to deliver respiratory care Greater need for RTs to be involved in research Require RT to be adept at understanding practical ramifications of published research 18 Current Status of Respiratory Care Within the Health-Care System Most respiratory care is provided in the acute care setting, the ICU, and the ED, where necessary respiratory interventions are aggressive, often life-saving, and frequently include mechanical ventilation High prevalence of several specific pulmonary conditions in the US, the proportion of all acute-care patients with respiratory issues is: Large Often involves hospitalization Responsible for large majority of respiratory care 19 9
Current and Future Human Resource Issues 2005 AARC human resources study projects 132,651 active RTs 19% greater than that in the 2000 study United States Bureau of Labor Statistics reported 121,000 RTs employed in 2006 predict 19% increase need for 145,000 by 2016 Center for Health Workforce Studies reported in 2004 that RTs unevenly distributed District of Columbia: 56/100,000 population Utah: 20/100,000 population United States mean: 32/100,000 20 Current and Future Human Resource Issues Location 74% of RTs work at least part-time in acute care. 61% of RTs work in urban areas and 38.5% in rural Gender 60:40 female to male ratio Age and Tenure mean age of active RTs in 2005 was 45 years mean years of experience was 19 years average age increased by 4.6 years since 2000 Few RTs older than 65 years actively practicing 21 10
Respiratory Care Education Programs: Graduates 24,150 graduates between 2004 and 2007 average of 6,048 graduates/yr 9.5% graduated from baccalaureate or masters degree programs Graduates increased by 19% per year in 2005 &2006, but decreased by 19% in 2007 22 Respiratory Care Education Programs: Educators Retiring personnel between 2005 to 2015 47.5% of program directors 34.2% of directors of clinical education Loss of key program personnel is a serious problem will require more graduates with baccalaureate & masters degrees to replace retired faculty members Current programs consist of: 34 entry-level 341 advanced level 10 polysomnography programs 23 11
Recent AARC Board Action Ad Hoc Committee on 2015 & Beyond That the AARC BOD accept the direction for the future of health care as recommended by the publication Creating a Vision for Respiratory Care in 2015 and Beyond Kacmarek, Durbin, Barnes, Kaegler, Walton, O Neil. RESPIR CARE 2009;54(3):375-389. 24 Recognized methods to improve health and reduce costs Education of patients, professionals, and each other is an essential skill for RTs important in reducing recidivism in patients with chronic respiratory disease Protocolized care (best practices) Disease management and self-management Ambulatory Care Preventive care Risk-factor modulation Smoking cessation 25 12
Recent AARC Board Action AARC Executive Office That the AARC Board of Directors directs the Management Section Chair to initiate a project to encourage respiratory care managers to look for and seize opportunities described in the manuscript entitled, Creating a Vision for Respiratory Care in 2015 and Beyond Kacmarek, Durbin, Barnes, Kaegler, Walton, O Neil. RESPIR CARE 2009;54(3):375-389. 26 2 nd Consensus Conference: Dallas, Texas April 6-8, 2009 27 13
Key Components Goal: to identify specific competencies necessary to assure safe and effective execution of RT roles and responsibilities upon entry into practice in 2015. Workforce education needed to assume newly emerging responsibilities of changing healthcare system with a close look at graduate RTs competencies needed upon entry into practice Future specialty practice areas for experienced RTs are identified without defining specific competencies. 28 Deliverables Conference 2: To identify competencies required to fulfill the scope of practice described in the 1 st conference for graduate RTs and RT workforce Graduate RTs are those who begin practice immediately after completion of an accredited education program. RT workforce are practitioners with varying amounts of work experience and credentials Assumption: that the workforce must be at least as competent as the new graduate RT in 2015 Goal of Conference 3: To agree on a plan that ensures 2015 RT workforce and its graduates have developed competencies identified by the second conference 29 14
How Healthcare Executive Decisions Impact the Workforce Perfect Storm - Economies impact on healthcare Hospital administrators believe healthcare financing system is broken Medicare payments have declined since 2000 Steps to increase productivity & enhance quality by consolidating staff functions Case management and disease management Understanding & implementation of evidenced-based protocols & best practices 30 Impact of Economy on 568 Hospitals: Dealing With the Poor Economy American Hospital Association. Report on the economic crisis: initial impact on hospitals. November 2008. http://www.aha.org/aha/ content/2008/pdf 081119econcrisisreport.pdf. Accessed March 4, 2010 31 15
How Healthcare Executive Decisions Impact the Workforce Skills as patient educators & perspective on healthcare outside of technical areas are needed to support these expanded responsibilities Strategies for reducing healthcare costs, such as increasing productivity, consolidation of service lines, and a greater emphasis on wellness are needed Administrators will expect RTs to be comfortable with patient information, to know what to do with it, to adapt to a rapidly changing environment, and be willing to take on additional responsibilities 32 How Healthcare Executive Decisions Impact the Workforce A competent RT workforce in 2015 and beyond must focus on: Improving quality & reducing costs through utilization of evidence-based practice protocols & improving patient movement across the continuum of care The workforce will soon be asked to assume new responsibilities, and RT graduates will enter a profession with an expanded scope of practice 33 16
Post-Conference Work Distributed edited version of developed competencies through Web-based survey to all conference attendees Survey designed to register approval or disapproval of 73 competencies needed by RT graduate therapists and current workforce in2015 Survey used a 5-category Likert design to determine the extent of approval with the competency definitions: 5 strongly agree, 4 agree, 3 undecided, 2 disagree, or 1 strongly disagree General competencies agreement determined by > 80% of respondents indicating approval (4) or strong approval (5) 34 Results Web-based survey was completed by 28 (76%) of 37 eligible conference participants (5 AARC staff members excluded) An 80% or higher approval was used to determine general agreement on 69 of the 73 competency definitions on the survey Limited agreement reached on 4 competency definitions that were approved by only 61 72% of the survey respondents The sense of the group was that, upon entry into practice in 2015, a graduate RT and RTs already in the workforce must possess 69 competencies in 7 major areas 35 17
Competency Area I: Diagnostics Pulmonary Function Technology Sleep Invasive Diagnostic Procedures 36 Competency Area II: Disease Management Chronic Disease Management Acute Disease Management 37 18
Competency Area III: Evidence-Based Medicine & Respiratory Care Protocols Evidence-Based Medicine Respiratory Care Protocols 38 Competency Area IV: Patient Assessment Patient Assessment Diagnostic Data Physical Examination 39 19
Competency Area V: Leadership Team Member Healthcare Regulatory Systems Written & Verbal Communication Healthcare Finance Team Leader 40 Competency Area VI: Emergency and Critical Care Emergency Care Critical Care 41 20
Respiratory Care Delivered to Critically Ill Patients by Respiratory Therapists Critical thinking & communication skills to discuss patient care during rounds and advocate for patient specific, best approach to care are essential Therapist relied upon as an expert source of information on when and how invasive, non-invasive and high frequency ventilation and the need for ECMO should be applied Essential care of critically ill patients requires broad knowledge of monitoring approaches Pharmacology: interaction with mechanical ventilation and to treat cardiovascular dysfunction 42 Competency Area VII: Therapeutics Assessment of Need for Therapy Assessment Prior to Therapy Administration of Therapy Evaluation of Therapy 43 21
Therapeutics - Application to Respiratory Care Practice Medical Gas Therapy Bronchial Hygiene Therapy Humidity Therapy Airway Management Aerosol Therapy Mechanical Ventilation Hyperinflation Therapy 44 The Transition From Graduate Therapist to Specialty Practice Graduate therapist transition into the workforce can best be described as moving from RRT to obtaining competence in one or more specialty areas of practice An experienced RT can practice without specialty credentials in any area of respiratory care Market forces drive consumers to seek credentialed specialists 45 22
Specialty Areas Identified in Small Group Sessions Summary of Conference 2 Role & responsibilities of RT workforce will change substantially in the near future in response to major US healthcare system changes This conference reached general agreement on competencies needed by graduate therapists entering the RT workforce in 2015 47 23
Conference 3: Summary The goal of this conference was to determine what changes in the profession are necessary to position RTs to fulfill the roles and responsibilities identified in conference one and to ensure that future and practicing RTs acquire the competencies identified in conference two. It was postulated that changes would be needed in the RT education, accreditation, and credentialing processes to meet the needs identified from conferences one and two. 24
2015 Committee Recommendations Education Credentials Licensure Transition of Respiratory Therapist Workforce Continuing Education Consortia and Cooperative Models Budgetary Resources Promotion of a Career Ladder American Respiratory Care Foundation Recommendation Time Lines for Major Policy Changes and Effective Dates for Implementation Recommendations Regarding: New Respiratory Care Programs Entry Level Degrees Entry Level Credentials 25
Moving Forward That AARC s leadership use the next year to conduct a briefing/listening tour to provide key stakeholder groups with an opportunity to better understand the project and allow AARC to gain additional input before it takes action on the any recommendations. 52 Agenda During the next year we will visit with key stakeholder groups to help them better understand the project and gain additional input from them before it takes action on recommendations generated by the Conference III stakeholder conferees. The AARC needs to carefully assess the impact of each potential approach to transition. 53 26
Agenda Also, it is reasonable to assume that other ideas, tactics, and strategies will be generated by these groups. Moreover, we recognize the concerns of all stakeholders and should do everything possible to promote clarity and understanding by all parties. 54 Summary of 2015 Conference Recommendations What has happen so far Transition recommendations can only be considered and accomplished with minimal impact on the workforce AARC BOD has accepted the attributes of 2015 Initiatives President Stewart has appointed an Ad-Hoc Committee for 2015 Gap Analysis Completed 55 27
We are not alone 56 The Future of Nursing Nurses should practice to the full extent of their education and training. Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression. Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States. Effective workforce planning and policy making require better data collection and an improved information infrastructure. 57 28
The Future of Nursing: Recommendations Remove scope-of-practice barriers Expand opportunities for nurses to lead and diffuse collaborative improvement efforts Implement nurse residency programs transition-to-practice program Increase the proportion of nurses with a baccalaureate degree to 80 percent by 2020 Double the number of nurses with a doctorate by 2020 Ensure that nurses engage in lifelong learning 58 The Future of Nursing: Recommendations Prepare and enable nurses to lead change to advance health Build an infrastructure for the collection and analysis of interprofessional health care workforce data 59 29
The Journey There are two mistakes one can make along the road to truth not going all the way, and not starting Buddha 60 Final Thought The road of life twists and turns and no two directions are ever the same. Yet our lessons come from the journey, not the destination. Don Williams, Jr. American Novelist 61 30