Cheryl Hoerr, MBA, RRT, FAARC
As I write this column at the end of 2014, it seems natural to reflect on the work I’ve successfully completed and anticipate the challenges of the coming year. My first order of business as your newly elected section chair is to thank each of you for your confidence in me and to emphasize that your active participation in the Management Section adds a tremendous amount of value for the professionals who are subscribed to this section. Each of you has a wealth of valuable knowledge and your willingness to share your hard-won experience has made my job a great deal easier at times.
I also want to offer a sincere thanks and “job well done” to Bill Cohagen, who has served admirably as our section chair for the past four years. His courage in sharing his professional struggles with us was inspiring and confidence-building. And I would like to express my appreciation to our volunteer editor of the Management Section Bulletin as well. Roger Berg has consistently done a great job in recruiting talented members to contribute content to our Bulletin. Thankfully, he has agreed to continue as our Bulletin editor, so keep him in mind if you have a desire to do some professional writing.
It was great seeing so many of you at AARC Congress 2014. Attendance at our annual section meeting had been waning for the past several years, so it was exciting to come together and hear so many voices. As the 2015 Summer Forum approaches I want to take this opportunity to encourage each of you to do whatever is necessary to be in attendance. The programming for the Summer Forum is specifically targeted to managers and the plan is to provide each of you with the unrivaled opportunity to network with colleagues while gaining critical, timely insights into your changing role as a leader in our profession.
Our new AARC president, Frank Salvatore, has announced an impressive list of goals for the coming year. One of his primary goals is to increase membership in the AARC. The old saying, “there is strength in numbers,” has never been more applicable to our profession as we continue to face the challenge of bringing meaningful patient-focused legislation before Congress and anticipate further challenges to our professional licensure.
As leaders, each one of us plays a critical role in advocating for the value of membership, including the critical role that increased numbers may play in our future professional survival. The AARC is a vocal advocate for our profession, but our voice is almost drowned out by other organizations with much larger memberships. We have reached a critical point, and it is imperative that each and every respiratory therapist joins and maintains his/her membership in the AARC. Can we, as respiratory leaders, develop and implement a workable plan to persuade nonmembers to join? I would be very interested in your input and ideas.
Finally, there is no denying that this is a stressful time for anyone working in the health care field. There is much uncertainty about what the future holds for our profession, and there is also no doubt that we must adapt our profession in order to survive into the future. For my part I see a bright future for the respiratory profession, with expanded patient-centered disease management responsibilities replacing the task oriented therapy approach of the past. But this brave new future will require vision, hard work, and a willingness to step out of our established comfort zone. I’m ready for a change in 2015…how about you?
Bill Cohagen, RRT, MSHCA, FAARC
Allen has been a mainstay in the field of respiratory care in Colorado for many years. He has worked at a number of different institutions while also serving as an instructor for the respiratory care program at Pima Medical Institute. He has been a part of the Colorado Society for Respiratory Care board of directors for many years, serving in all capacities, and he was a part of the AARC Political Action Committee for so many years that he was the longest tenured participant ever in the role.
Two years ago, because of his many accomplishments, he was awarded recognition as a Fellow of the American Association for Respiratory Care, or “FAARC.”
Many people who have already accomplished so much would be satisfied to “coast” in the latter years of their career, but not Allen! Over the past year, he has continued to push his University of Colorado Hospital respiratory care department and the AARC forward towards greater levels of professionalism and service.
Among Allen’s many accomplishments:
Simulation in Healthcare:
Allen continues to push the profession forward not only in Colorado, but also nationwide. We congratulate him on his receipt of our 2014 Specialty Practitioner of the Year Award.
Richard M. Ford, BS, RRT, FAARC, Director of Pulmonary Services, UC San Diego Health System, San Diego, CA
In the January 1971 edition of Respiratory Therapy News, Dr. D.S. Tysinger wrote an article titled “Lessons Learned in Twenty Years’ Experience in Treating the Chronic Lung Patient.” His message was one of opportunity for improvement. He declared that patients with chronic lung disease are likely to get improper, ineffective, and in some cases, detrimental and even lethal treatment, specifically in the home environment.
Ironically, while the field of respiratory care has experienced tremendous advancement in understanding the diagnosis and treatment of COPD since 1971, we can still agree that today such patients are still at risk. Luckily, there are new opportunities to improve outcomes.
With the significant and unsustainable cost of health care in the U.S., the Affordable Care Act (ACA) emerged. The Readmissions Reduction Program within the ACA provides for significant penalties for readmission of COPD patients to acute care hospitals. COPD was included in the program as of October 2014, with penalties for readmissions for pneumonia, myocardial infarction, heart failure, and COPD amounting to as much as 3% of total Medicare annual payments.
While COPD was just included last year and will impact penalties applied in 2015, there are concerns over the program. Some have expressed that the program may actually place patients at increased risk, in that centers that are in underserved communities and already struggling may incur further financial losses that will hinder their ability to serve such communities.
For example, the program does not take into account the socio-economic, literacy level, or homeless population of a community, despite the fact that these factors greatly impact the ability of caregivers to influence care once a patient is discharged. There are also planned readmissions for necessary follow-up care to consider, and mechanisms are being refined to ensure readmissions under these conditions are exempt.
Lastly there are also centers, such as UCSD, in which there is a profit in COPD admissions/readmissions. In the case of UCSD, the total gain of taking care of patients readmitted for COPD is estimated to be greater than the penalty that would be incurred by avoiding these 30 day readmissions. But regardless of the financial incentives, improving the care and outcomes for these patients is the right thing to do.
To that end, we have programs in place at UCSD that provide for a positive margin in the care of such patients.
The initiatives already in place include:
With these programs in place, the cost of treating COPD patients produced a positive gain over a length of stay of 4.5 days. These programs have also impacted the 30-day readmission rate. In 2013 the readmission rate had increased to 27%, and over the 2014 period it dropped to 17.6%. We also recognized we could have a greater impact on the cost of inpatient care, the continuity of care, and the transition to home if we could allocate additional resources to coordinate the care of these patients.
The addition of “COPD coordinators” (six individuals amounting to one FTE) was approved and will be implemented this year to assist with sustaining existing programs and increasing physician compliance with the COPD order set. These coordinators will also provide additional focus on patient/family education; medication management; development of a personalized COPD Action Plan; and referrals to PFT, pulmonary rehab, and smoking cessation; as well as personalized telephone follow-up once the patient has been discharged.
Regardless of the financial incentives, we must ensure compliance with the recommendations contained in the GOLD guidelines and make sure COPD patients not only receive the most effective and efficient care possible while in the hospital but also have access to the services they need to stay healthy post discharge. Never has there been a greater opportunity for the RT.
Tim Buckley, MSc, RRT, FAARC, System Director, Respiratory Care, Sleep Medicine and Critical Care, Summa Health System, Akron, OH
“Value based health care” is a term that has been increasing in use for the past several years. I think it is not well understood by many of us. At the recent AARC Congress in Las Vegas, it was apparent that while our profession is focused on providing value, there remains a great deal of confusion as to what that actually means and how can we show the value we provide.
According to Porter, “Value should always be defined around the customer.”1 He goes on to state, “Since value depends on results, not inputs, value in health care is measured by the outcomes achieved, not the volume of services delivered, and shifting the focus from volume to value is a central challenge.” Porter emphasizes that value is not measured by the process of care used; while measurement and improvement are important tactics, they are “no substitute for measuring outcomes and costs.”1
Value-based purchasing is now widely seen as a replacement for traditional fee-for-service reimbursement.2
This represents a fundamental change in how we manage respiratory care departments. Our whole model of care delivery and management is based on fee-for-service. We are assigned FTEs based on the number of procedures we bill for and the time standards that are accepted by our hospital administration. Capital requests are evaluated by the amount of revenue they can produce.
Even at the staff level, most RTs can quickly calculate the assignment they are given each shift in their heads. As effective managers we need to shift the calculus of both our administrators and staff RTs from measuring volume to measuring value.
In a recent meeting, the director of cardiovascular services for our system described the current payment environment as having “a foot in two canoes.” We are still having our performance measured under fee-for-service, but are expected to generate value-based outcomes. The change from fee-for-service to value based payment is complex and difficult, a juggling act with financial benefits that are promised, but by no means assured.2
How does value based care affect the RT department? Like many hospitals we have recently completed our budget process for 2015. The challenge we had in all areas, including RT, was to meet standards for staffing acute care hospitals where we have seen a decreased patient volume and yet provide better outcomes and more value to our customers (payers, physicians, families, and most importantly, patients). The same dilemma exists as we plan capital expenditures. What is the best investment for our future?
For the RT department, the answer to that question is especially difficult. The suggestion for the future is to focus on outcomes that are based on best evidence and work to get unnecessary costs out of the system.2 The challenge is to be able to document those outcomes and cost reductions, while continuing to manage the day-to-day activities of your department. It is also a challenge to think about the hospital as not the only site of care, but as just one of many opportunities to provide care and treatment.
In our system we have been challenged to rethink how respiratory care is provided as the traditional silos are torn down. We have seen graphically that we can provide excellent care to a COPD patient in the hospital, but when that patient is discharged, he returns because he did not use his prescribed medication correctly. Was this an education issue, an economic issue, or an access issue? I can show you cases where the problem causing the readmission within the magic 30 days was centered in each of these areas.
What are some examples of value-added RT services? As an AARC member, you have access to a number of resources. Let’s take a look at articles published in AARC Times over the past year for some ideas.
The University of Virginia highlighted a program involving the RT in post-sedation non-invasive monitoring of patients.3 The RTs proved their value by managing the risks specific to the cardiopulmonary system in patients undergoing moderate sedation. Airway management, hypoxia management, and hypercapnia management are all roles that RTs are ideally suited for by training and background. Do your RTs have role in the PACU or do they just respond to codes?
Klingensmith Healthcare described an innovative program to provide respiratory care in the home.4 By utilizing the unique skills that RTs possess, the continuum of care from the acute care setting to the home is supported. The RTs recognize risk factors that may not be apparent in the hospital, and mitigate those factors so that the patient can safely remain in her home. Does your hospital have a relationship with an agency that provides home RT?
Baylor University Medical Center described a program that utilizes a Certified Asthma Educator/RRT to serve as an asthma navigator.5 This individual works with asthma patients and their families to improve asthma outcomes, decrease the cost of care, and improve the quality of life.
A similar role exists for RTs at Children’s National Medical Center.6 Who manages your asthma patients? What about COPD, cystic fibrosis, or lung cancer? My system piloted an RT as a lung nodule navigator, and we are likely adding an additional RT in this role in 2015, based on the value we provide to this population.
Back in the hospital, who manages your patients on inhaled medications for the control of pulmonary hypertension? Rush Presbyterian St. Luke’s described a role for the RT in the administration of nitric oxide and prostaglandins in the ICUs.7 Our health system has also recently added this role for selected RTs. The value of the RT is that he understands the hemodynamics and can coordinate the ventilator care that the patient is receiving.
How about smoking cessation? RTs have long been involved in the delivery of smoking cessation services to their patients and communities. Besides their understanding of the pulmonary impact of tobacco products, RTs are also experts in patient education and assessment, as well as proper medication use.8 Talk about adding value! Our system uses smoking cessation provided by RTs as support for the Medicare Meaningful Use program. Our patient education efforts and documentation alone have earned our health system a payment of $2 million for meeting the program targets.
As leaders in respiratory care, we need to continue to use the skills of our RTs to provide better outcomes and eliminate unnecessary costs. It is the basis of proving our value in the new world of value based reimbursement. And if we are adding value, we need to find ways of documenting that value as well by showing that we can reduce length of stay or avoid complications, or keep patients home when discharged. If we are able to measure and prove our value, maybe we can stop counting aerosol treatments.
Bill Cohagen, RRT, MSHCA, FAARC
As we get further into the new year, we will face many challenges as well as many opportunities. How you face them is up to you.
Now is the time to move. We should hit these changes head on and improve the profession for future generations. You can accomplish this by throwing out some of the old and useless procedures that we have complained about in the past and start doing new things that will add value to your organizations and the profession. Things like line placement, pulmonary discharge planning and outpatient outreach programs, or even ARDS/ALI care teams, to name a few. Whatever you choose to do, just do and master it!
You can invent your own initiatives, or choose to follow others by taking existing programs that will fit your organizational needs and follow the chain of success. Just because it has been done before does not mean you shouldn’t adopt it. If it is worthwhile, you can do it just as well as others, or even — in the spirit of greatness — help perfect it.
Of course, you could just decide to just fly low and ride out your time until retirement. I believe if that’s your choice, the best thing you can do for your staff and your profession is to retire now. All you will be doing is setting us back light years, possibly ridding the facility you are at of a respiratory department along the way. It is happening to those who play ostrich and try to stick their heads in the sand, hoping the Affordable Care Act will go away.
As I look back over my career, I am proud to be a part of this ever-evolving profession that allows us to create our destiny and be what we want to be. Without this mindset from my mentors, I would still be looking for my purpose in life.
The future is yours, but what you do with it will ultimately effect the future of others. Think about it.
Recruit a New Member: Know an AARC member who could benefit from section membership? Direct them to section sign up. It’s the easiest way to add section membership to their overall membership package.
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