Viewing the Future of Home Care
Upon the Issue of Competency Rests the Fortunes of RTs in Home Care
By Michael Gibbons
When drawing up their reimbursement scheme for home care years ago, Medicare’s money mavens didn’t see a need to pay for respiratory therapistswho weren’t even therapists in those days but OJTs, unlicensed and lacking credentials. Hire OJTs if you want, home care executives were told, but pay them out of your equipment rental fees.
Opportunities for therapists in home care have remained moribund ever since. If that’s not troubling enough, consider the imminent future. The Balanced Budget Act of 1997 will bring the prospective payment system to home health sometime in late 2000. It’s the same PPS that continues to reduce jobs for all ancillary health professions in the skilled nursing world. Won’t it do the same, or worse, for RTs in home care?
Maybe not, said Scott Bartow, RRT.
“Under PPS, there are chances to grow from this very humble current existence,” Bartow told ADVANCE. “As a businessman, any time I see change, I see opportunity.”
Thanks to PPS, home care continues, ironically, to grow in the areas of oxygen, sleep apnea, asthma management and home ventilator care, he pointed out. “PPS made it difficult for long-term care facilities to accept trached ventilator patients and others acutely ill,” he said. “So they backlog in hospitals, causing an enhanced desire to place them in home care. These are markets where therapists can have an impact.”
With PPS coming, “agencies would be smart to utilize RTs because it’s no longer as critical what discipline is doing the treatment as the outcome,” Bartow added. “RTs could reduce a company’s overall expenditures for a patient with COPD or asthma because of their equipment knowledge and their disease state management knowledge. I think the smart agencies will use therapists.”
If all this sounds like wishful thinking, realize that Bartow has more insight into the thought processes of home care execs than do most RTs. He is, after all, vice president of Ventilatory Care Management of Wisconsin, a provider of home medical equipment and related services.
So tell us, Mr. Vice President, do you employ respiratory therapists?
“We do use RTs,” Bartow said. “Is it more expensive to provide an RT rather than a driver to perform some of our services? Yes. Is it of value? Yes. You could train some of our service reps to set up oxygen. It would work 95 percent of the time. But that other five percent might be problematic. It might be really important to have someone with a medical background capable of assessment, someone who can function at a higher level.”
It’s that image of a van driver faced with a medical emergency in the home that crystallizes the issue of competency, surely the watchword of the moment for a profession desperate to gain some traction outside the acute care arena. For upon the principle of competency rests the fortunes of therapists seeking to enter skilled nursing or home care.
Respiratory care leaders don’t want regulators pronouncing as competent anyone who has watched a five-minute instructional video or handled a pulse oximeter for 10 minutes.
“The competency issue transcends all areas of service and disciplines,” Bartow said. “It’s not that other disciplines can’t learn these activities, but RTs learn them directly in their education and training. Can nurses give oxygen? Certainly. But RTs are already trained in it. Who is the best person to assess a COPD patient and determine what equipment will be most appropriate?”
The AARC doesn’t want to antagonize other health professions. But it doesn’t want them eating its bread and butter either.
“We continue to beat the drum that patients in the home care setting need access to experts in respiratory care,” said AARC Executive Director Sam Giordano, MBA, RRT. “We believe those patients have a right to that resource. We think the rules are discriminatory. We’re prepared to proceed with a new process that HCFA has developed to allow parties to petition for change or amend coverage rules.”
Patient safety is one form of ammunition in the competency battle. Money is another. More than one AARC-funded outcomes study has demonstrated hospitals frequently hurt their bottom lines by misallocating respiratory services.
“We drive home the point that RTs are the best qualified to make sure an order is appropriate by reviewing the order with the attending physician and by assessing the patient’s condition,” Giordano said. “There will be an incentive for the home care community to use RTs as gatekeepers to avoid treatments with no clinical benefits. Right now, the incentive is to provide services. Once they transition to PPS, the incentive will be to provide the optimum level of services, no more, no less.”
This past summer, the AARC took the issue of competency directly to the people. On June 28-29, the AARC sponsored a meeting at the Citizens’ Advocacy Center in Arlie, Va., between its representatives and those of 20 consumer advocacy groups representing powerful lobbying organizations like the American Association for Retired Persons.
AARC officials described the education and competency testing RTs receive. They made consumer advocates aware, for example, that not only nurses but also nursing aides perform respiratory care in the nation’s hospitals.
“It did get their attention,” said Cheryl West, MHA, the AARC’s director of government affairs. “In my perfect world, AARP leaders would smack themselves in the forehead and say, ‘We must fix this.’ We raised their awareness about what they should be thinking about.”
While looking ahead to home care, AARC officials remain focused on establishing respiratory therapy competency requirements for SNFs. In fact, how they fare in SNFs could determine future success in home care.
“If we can win the battle for competency in SNFs, we can stake an outpost in other practice settings, including the home care arena,” West said. “We could say, ‘If you’re not going to hire therapists, you have to demonstrate that others who do respiratory therapy know what they’re doing.'”
The AARC is negotiating with Sen. William Roth (R-Del.) to incorporate competency into any bill pertaining to persons providing respiratory services in SNFs, according to Giordano.
“We’ve developed language that describes minimum competency for all persons who deliver respiratory care,” he said. “We’re working with Sen. Roth to push for this language to be included in a bill that will be considered seriously by Congress this fall. People who perform respiratory services must demonstrate that they possess the same competency levels as RTs. If the Roth language is successful in SNFs, we would point out the need for competency testing in home care too.”
If competency testing did become law in both settings, the AARC would then approach SNFs and home care agencies as follows: Why spend money devising competency tests? Why not just hire RTs? They’ve already proven their competency. “We would encourage employers that, rather than develop their own tests, they could just hire the people who have already submitted to competency testing,” Giordano said.
Meanwhile, the AARC continues to challenge PPS reimbursement in SNFs and outpatient rehab, partially in hopes that any success will have a “spillover” effect into home care. A 1998 AARC outcomes study established that costs to treat respiratory patients in SNFs were not duly recognized. A complementary study commissioned this year established that RTs make a difference in mortality and LOS.
“Our evidence is being recognized and incorporated in many decisions on bills to provide relief to SNFs,” Giordano said. “We’re working with Sen. Orrin Hatch (R-Utah) on a bill for increased payment under the RUGs system for respiratory patients.”
West added, “If you can show that HCFA was in error in calculating payments for the non-therapy ancillary category, which is where respiratory care in SNFs falls, you may have a better chance of affecting PPS in home care and pulmonary rehab. You could have a spillover effect.”
The job of enforcing any competency legislation would fall in part to the Joint Commission for Health Care Accreditation (JCAHO). The AARC has a friend in high places at JCAHO: the aforementioned Bartow.
In February, Bartow was elected chairman of the Joint Commission’s Technical Advisory Committee (PTAC) for Home Care Accreditation, a 28-person committee that helps JCAHO develop accreditation standards for home care agencies.
“As chair, I’m cautious not to abuse my role. But there are times when it’s appropriate to comment on competency in respiratory care, and I take that opportunity to do so,” he said.
Bartow has also provided JCAHO with its definition of pulmonary rehab. He considers pulmonary rehab for discharged patients another area that under-utilizes RTs.
“One area with the greatest potential is what I call ‘the myth of continuum of care,'” he said. “When you include an RT as part of the discharge team, you have a safer, more efficient, more appropriate discharge, but you rarely see it to the extent it could be used.”
RTs can establish themselves in alternate care settings, Bartow concluded, by “pounding their message home” about competency, using clinical practice guidelines and maintaining a patient focus. They should also try to upgrade their education.
Michael Gibbons is an ADVANCE associate editor.