Notes From the Chair: AARC Congress has Lots to Offer
Kimberly Wiles, BS, RRT, CPFT
As the summer comes to a close, it is time to start making plans to attend AARC Congress 2014 in Las Vegas. The program kicks off with a pre-session on Dec. 8, followed by the opening day on Dec. 9. The meeting will end with a great closing ceremony on Dec. 12. Our section members came through by submitting a lot of great home care topics, and the Program Committee listened. There are 20-plus lectures directly related to home respiratory care on the agenda, as well as many that are indirectly related.
We will also hold our annual section meeting on Wednesday. This is a great opportunity to become more involved and meet some of your fellow home care therapists. Check out the Program and make your reservations now! See you in Vegas!
Home Care Competencies: Are We Doing Enough for Our Students?
Kimberly S. Wiles, BS, RRT, CPFT, Home Care Section Chair, and Lindsay Fox, MEd, RRT-NPS, Program Coordinator, Southwestern Illinois College/St. Elizabeth Hospital, Belleville, IL
As we enter into the future and an era of change, we have to evaluate our care at all levels and ask ourselves, is the graduate respiratory therapist prepared to enter the unchartered, uncontrollable environment of the home?
Many health care treatments and diagnostics that were once offered only in a hospital or a physician’s office can now be safely, effectively, and efficiently provided in patients’ homes by skilled clinicians. Home health care is generally less expensive, more convenient, and as effective as care provided in a hospital or skilled nursing facility.1 Many patients are being discharged sooner and in a more critical state requiring multiple treatment modalities. Are our students prepared to handle these patients in an uncontrolled environment that requires critical thinking skills?
Home care lacking in the curriculum
So what does the current curriculum look like for the respiratory student as it relates to home care? According to one instructor who taught in two associate degree programs and two baccalaureate programs, the time allotted in the didactic and/or lab portion of the program varies greatly. In some programs, the only discussion of home care comes in the context of other courses. For example, the students may learn about oxygen delivery devices used in the home during a basic respiratory care lecture. They may learn about home ventilation (invasive and noninvasive) in the mechanical ventilation course. Is this enough to adequately prepare the student for the home care environment? Equipment used in the home is vastly different than equipment used in the acute care setting, not to mention that it is being utilized in an uncontrolled environment and various adaptations need to be made in order to accommodate some of the equipment.
Associate degree programs have to satisfy general education requirements as well as the necessary respiratory care coursework in a set number of credit hours, which is dependent upon their state. This can be challenging due to the fact that some community colleges set the maximum credit hours at 60-70 hours. A bachelor of respiratory therapy program may have more flexibility to fit in a course that is specific to home care. However, after researching a few websites of bachelor’s programs it appears that there is more of an emphasis on pulmonary rehabilitation, research, management, community/patient health education, and pulmonary function testing than on home care.
What the standards say
The Commission on Accreditation for Respiratory Care (CoARC) lists the standards and the evidence of compliance for the curriculum of a respiratory care program in section 4.0 of the 2010 CoARC Accreditation Standards Manual.2 Standard 4.01 states, “The program must prepare students to meet the recognized competencies for registered respiratory therapists identified in these standards.” The standards do not list the competencies, but programs must show that there is documentation of competencies that demonstrate the student’s knowledge, technical skills, proficiency, and behaviors.
Standard 4.06 discusses the requirements of the respiratory care content in a respiratory program. According to this standard, “Respiratory Care content must include respiratory care of the adult, pediatric and newborn patient; health promotion, education, and disease management; fundamental principles of healthcare reimbursement; fundamental principles of evaluating current scientific literature; medical ethics; provision of health care services to patients with transmissible diseases; provision of services for and management of patients with special needs; community respiratory health; medical emergencies; and legal and ethical aspects of respiratory care practice.” There is nothing in this standard that states that home care is required.
Brief rotations fall short
The respiratory therapist’s role in the home setting will inevitably be changing and it will be important to understand that this means a possible shift of clinical experience in this setting. Currently, many programs treat home care rotations as a specialty along with areas such as pulmonary rehabilitation, polysomnography, and pulmonary function testing. These specialty rotations may include a one or two day home care rotation that allows the student to tour the facility, handle the equipment used in home care, and observe the therapists in the home.
With only a one or two day rotation in the home, how can programs deliver a quality clinical experience for their students? Such a short rotation provides only a glimpse of the challenges that occur in the home. Perhaps it is time to evaluate students in this setting as they provide care and make decisions regarding the patient’s care plan. This would help to build the independent thinking skills that are essential for home care RTs to possess.
Of course, even if programs are able to add extra clinical time for the student to spend in the home care rotation, there are clinical obstacles that the director of clinical education may encounter—
- Adequate number of sites for the number of students willing to take rotations.
- Home care companies refusing to take students due to the recent changes to reimbursement and the lack of time their RTs have to work with students.
- Liability—some companies will not allow students to ride with the RT. This adds an extra financial burden for a student.
- Lack of standardization of RT protocols in the home.
One of the key home care competencies that should be included in the RT curriculum is the ability to assess the environment of care. This is essential in establishing the plan of care as it relates to the equipment being provided, as well as the disease state. In order to decrease health care costs, problem identification must occur in the patient’s home. The home environment may pose new problems for the patient when he goes home from the hospital. This is only one unique competency that exists, but if not carried out appropriately it can be a “game changer” when it comes to managing the patient in the home.
Now is the time
As we prepare for the future, now is the time to address the unique competencies required for the respiratory therapist to work in the home environment. Due to major changes and reductions in reimbursement for home medical equipment, many companies are decreasing and/or eliminating RT positions. The payers have made it clear that they are paying for the equipment and not the service, including the RT. But if the patient cannot or will not use the equipment provided due to lack of education or follow up, the patient will be admitted back to the hospital.
When there is not an RT in the home, the hospital RT will need to be well-versed in the competencies needed to help solve the problems encountered by the patient at home. Most home care RTs have worked in the hospital at some point, but very few hospital RTs have worked in the home. Their only home care experience might have been a rotation through a home care company that only provided a peak into the home environment without any “hands on” training. It is time for us to contemplate if a brief rotation is enough to provide what is needed for the future RT student.
Education is our passport to the future, for tomorrow belongs to the people who prepare for it today.―Malcolm X
- Centers for Medicare and Medicaid Services. Medicare and You. 2011.
- 2010 CoARC Standards for the Profession of Respiratory Care.
Out-of-the-Box Respiratory Home Care
Betsy Thomason, RRT, Senior RT at Millennium Respiratory Services, Whippany NJ; Owner, BT Breathing Training, LLC, Park Ridge, NJ
So, how does one become an out-of-the-box thinker? It’s a mindset, a perspective that can be acquired if you’re willing to explore your potential! People who think outside the box are eager learners, ready to initiate new ways of looking at the same old same old. As members of the human race, we all can become complacent or discouraged and need a shot in the arm—not a vaccine, but a conceptual infusion of brilliant new solutions.
For me, books are one infusion. I must admit, though, that I can get really bored learning only by reading written words or listening to lectures. I respond to movement—tossing ideas around, digging dirt in my garden, and moving a pencil on paper. The Doodle Revolution: Unlock the Power to Think Differently by Sunni Brown is the exception to boring books, and it is exceptional. It’s a compendium of visual learning available to anyone ready to challenge the perception of personal limits of any sort. Sunni Brown is ready to guide you to visual literacy, using doodling to resolve problems—professional or personal—and to have fun at the same time.
Consider another book: Air—The Restless Shaper of the World by William Bryant Login. The title intrigued me, and then the contents astounded me because I learned not just about the gases that surround us, but about the communities within which we live. Even though some of us enjoy being self-reliant—myself included—we all live and function intertwined in community.
Certainly, being self-reliant is an essential quality for a home care respiratory therapist. Also essential is the polar opposite—being a team player, as Login points out. The author says, “The right stuff for a pilot [replace with “home care respiratory therapist”] is not godlike independence. Rather, it is presence. It is the ability to respond to noise and trouble by querying your senses, the instruments, and your companions. To fly a plane [replace with “manage a ventilator”] through trouble is a creative act. The best captains [replace with “respiratory therapists”] are almost always the ones who ask for input.”
The take-away message for the out-of-the-box thinker is to be simultaneously independent and engaged in community. Speak up at staff meetings. Ask “what if” questions. Visualize the possibilities. Be the trail blazer with new ideas for health and safety. Dare to say the unmentionable. And then listen.
Where do you stand in relationship to the box?
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