Strategically Positioning Skilled Nursing Facilities for Success Under the Affordable Care Act

Beginning October 1, 2014, the Centers for Medicare and Medicaid Services (CMS) began to penalize acute care hospitals for readmitting patients diagnosed with Chronic Obstructive Pulmonary Disease (COPD) within 30 days of discharge. This was the result of the national Hospital Readmissions Reduction Program, established by the Affordable Care Act of 2010, which reduces payments to hospitals for excessive readmissions. The progressive percent reduction penalties for fiscal year (FY) 2013-2015 are provided below:

  • FY 2013 – 1% for all CMS reimbursements to a particular hospital with excess readmits
  • FY 2014 – 2% “
  • FY 2015 – 3% “

Any readmission is penalized if it occurs within 30 days, regardless of whether the patient was readmitted with a different diagnosis than the original, or if the patient readmits to a different hospital; however, the hospital reporting the initial diagnosis is still the one liable for the reimbursement penalty.

CMS penalty fees for FY 2013-2014 applied to the diagnoses of acute myocardial infarction, heart failure, and pneumonia. In 2013 alone, penalties totaled $2.2 million. In FY 2015, CMS added three more conditions to the readmission penalty list: arthroplasties of the total hip and total knee and COPD. These diagnoses will only compound the reductions in reimbursement hospitals will receive if they do not manage these conditions well moving forward.

COPD is one of the most difficult diseases to manage within this list of diagnoses. In 2012 over 1 million patients were admitted to acute care hospitals for an exacerbation of COPD;  in general, readmissions occur within 20% to 23% of cases. The direct costs of COPD in the US has been estimated at $32 billion in 2011; worldwide COPD is estimated to become the third leading cause of death by 2020.

Since COPD is a leading admitting diagnosis to acute care facilities, this new penalty has the potential to severely impact the financial health of already-struggling hospitals. It would be fair to conclude that hospitals will eventually only discharge their COPD and pneumonia patients to those post-acute care facilities that have excellent track records of respiratory disease management. Thus, long-term care and skilled nursing facilities should implement respiratory therapist-driven care paths to successfully manage patients suffering from COPD and pneumonia.

There are several clear advantages to using care paths according to the American College of Chest Physicians:

  1. Therapy can be adjusted more frequently in response to changes in the patient’s condition;
  2. Physicians are consulted for major clinical changes but not minor ones so nuisance calls can be avoided;
  3. Consistency of treatment is maintained and non-pulmonary physicians have the ability to use up-to-date methods of therapy by simply requesting that a protocol be instituted; and
  4. Respiratory therapists (RTs) are actively involved in achieving the goal of good patient outcomes instead of performing rigid tasks.

Respiratory-driven care paths are designed to maintain consistency with the medical staff’s respiratory care plans; ensure that therapy is timely, appropriate, and driven by the patient’s most recent condition; ensure cost-effective strategies  are implemented when appropriate; and most importantly, ensure that providers are notified of any clinical conditions that are outside the scope of the protocol.

Respiratory therapy care paths should be the responsibility of licensed clinicians who have achieved strict levels of advanced education, training, and experience in respiratory assessment and treatment modalities. RTs are licensed clinical professionals who possess these skills in abundance. RTs are obligated to complete either a two-year associate’s degree or a four-year baccalaureate degree in respiratory therapy assessment and technology. Upon graduation, RTs are qualified to undergo three national examinations, which upon passing leads to the Registered Respiratory Therapist (RRT) credential. The RRT credential demonstrates that the holding RT has the relevant critical thinking skills necessary to assess and make the correct decisions when treating patients with respiratory-related conditions.

By having RTs coordinate these care paths, long-term care and skilled nursing facilities will be best situated in maintaining lower readmission hospital rates versus national averages. The U.S average for 30 day re-hospitalization rates are 17.3% for pneumonia and 20.7% for COPD ( Kingston Healthcare Company based in Toledo, Ohio has three skilled and long-term nursing facilities in Ohio and Indiana that employee RTs. In one such facility where they have RTs in-house 7 days/week, 12-16 hours/day, Kingston reported the following combined RTH rates for COPD & pneumonia in FY 2016:

  • 1st Quarter: 13.3%
  • 2nd Quarter:3.7%
  • 3rd Quarter: 7.69%
  • 4th Quarter: 12.5%

The approximate costs associated with employing RCPs in the skilled environment in the Midwest are as follows:

  • Human resource costs: $124,300 annually for 2 full-time respiratory therapists and $279,054 for 4.49 full-time therapists
  • Supply costs: $42,000 annually per facility
  • Capitol one-time, start-up cost: $26,000

Regardless of initial, start-up expenses, the benefits outweigh the associated costs over the long-run. It is in the best interest of patients who suffer from acute and chronic lung disease that they first seek facilities that employee RTs to assess and treat respiratory-related conditions, and that CMS adopt a reimbursement model that will allow skilled nursing facilities to incorporate RTs and complex respiratory assessment and therapy into their resident care models.

Four Ways Respiratory Therapists Can Achieve Excellence

US Navy 030420-N-4182M-002 Petty Officer 1st C...
US Navy 030420-N-4182M-002 Petty Officer 1st Class Timothy Jackson helps and Iraqi patient breathe in the Intensive Care Unit (ICU) aboard the Military Sealift Command (MSC) ship USNS Comfort (T-AH 20) (Photo credit: Wikipedia)

Look around you. The way you perform your duties as a respiratory therapist (RT) is not the same as it was ten or even five years ago. Every year it seems that RTs are called to do more with less. And unfortunately, there doesn’t seem to be any possibility of these high therapist-to-patient ratios improving anytime soon. What must individual RTs do to grow respect for their profession at a time when their valuable skills and knowledge are becoming less visible due to having less time to spend with their patients? The answer is that RTs must strive for excellence in every facet of their professional lives.

The key to excellence is having the keen ability to evenly balance between focusing on improving critical thinking skills, providing exceptional customer service, improving quality of work life, and being good financial stewards of resources. Focusing on one of these essential components to the detriment of the others is the quickest way of achieving mediocrity. If the respiratory therapy profession is going to grow and thrive within the 21st century, every one of its members must seek balance between each of the preceding four quadrants of excellence.

1. Focus on Customer Service

It is a simple fact that in the US today, patients have many choices in regards to where they receive their healthcare. Patients no longer have to put up with poor customer service; they can simply choose to go elsewhere. It is crucial, therefore, that RTs represent their profession in the most respectable manner possible in order to help their employers maintain a competitive edge. The more RTs improve the marketability of their employers, the more value and clout they will hold in times of organizational downsizing.

Listening to hospital administrators continually stress the importance of customer service sometimes has the tendency to make frontline clinicians believe that the higher-ups are more concerned with customer service than clinical quality. But those who think that there is a wall of separation between clinical quality and customer service should rethink this idea. Customer service is directly proportional to the perceived quality of healthcare that patients receive. The majority of patients who receive respiratory therapy do not understand the technical components of their therapy. This is because people only understand what they see and hear. If patients are not educated about their therapy and why it’s important, they will not understand the value of RTs in their overall plan of care.

As with any other economic market, the financial health of any healthcare organization is directly related to the number of patients they serve. The more patients who go elsewhere to obtain better service, the more these employers will lack the ability to hire additional caregivers and purchase new capital equipment. In the end, it is the patients who suffer. Therefore, RTs should be customer service champions within their healthcare organizations–not only for their own personal job security, but for the well being of their patients.

2. Focus on Quality of Worklife

The easiest way for respiratory therapists to foster good quality of worklife is to be exceptional communicators with everyone on their healthcare team. More times than not, RTs tend to feel “used and abused” because their place within the healthcare team is not respected until a patient’s airway is compromised. However, the respiratory therapy profession is not intentionally overlooked. The old cliché, “Out of sight, out of mind” plays a huge role in answering this seemingly disrespectful attitude toward individual respiratory therapists. Spending the majority of their time in their own particular fields of expertise sometimes blinds other healthcare professionals to the insights and skills of other professions.

RCP’s can help offset this trend by taking every opportunity to educate their fellow healthcare professionals about the knowledge, skills, and interventions that they have to offer. This can be accomplished in a way that is as simple as assessing the patient and discussing their findings and recommendations to all who are involved in their patient’s plan of care.

3. Focus on Financial Responsibility

RCP’s should embody financial responsibility. If the profession is to gain more and more national recognition, those who fall under its banner must be frugal with their resources–especially in uncertain financial times. Unfortunately, some RTs fail to understand the delicate balance between clinical quality and the financial health of the organizations for which they work.

Respiratory therapists can begin to change this unhealthy outlook by viewing their administrators as fellow members of the healthcare team who are also suffering from similar challenges. Just as RTs are required to provide more care with fewer therapists, healthcare administrators continually have to seek creative ways of providing quality services in the midst of ever-shrinking revenues.

Individual RTs can do their part in saving valuable resources by utilizing supplies in an efficient manner, limiting nosocomial infections by practicing good infection control techniques, and giving an honest day’s work for an honest day’s pay. Showing up to work on time as scheduled not only saves the hospital money through reducing overtime expenses; it first and foremost benefits the patient. Chronically being late or absent from work infringes upon timely and consistent patient care. Dependability, on the other hand, demonstrates a high level of professionalism and respect for the patients in need of respiratory care. The more RTs contribute to a healthy bottom line, the more valuable they will become to those who are responsible for keeping their healthcare organization financially strong.

4. Focus on Critical Thinking Skills

How many times have you heard a fellow therapist say, “If those bean counters in Administration would quit focusing so much attention on the bottom line and spend more resources on improving clinical quality, things would be a lot better around here.” Although having the necessary tools available is crucial to providing good patient care, clinical quality does not magically improve just because there is more money available. Good clinical quality is fundamentally the result of a strong, honest work ethic that is demonstrated through a continual devotion to improving one’s self and one’s profession.

Throughout the coming years, respiratory therapists are going to continually be asked to be more productive with fewer resources. However, this trend will not be because hospital administrators do not want to hire more employees, it will be because the number of practicing RTs will not be able to match the demand that the retiring Baby Boomer generation will inevitably place on their services. RTs will have no choice but to adapt.

One specific way in which we will see the respiratory care profession adapt to the coming changes in healthcare will be through the process of becoming less technical and more therapeutic. This shift will naturally occur as RTs begin to use more of their time employing their critical thinking skills to determine the best plan of care for their patients, and less time in the technical aspects of their jobs that may or may not have been beneficial for those they serve.

For example, Kingston of Miamisburg (KOM), a skilled rehabilitation and long-term nursing facility in Miamisburg, Ohio, opened a respiratory therapy department in 2014 to improve the quality of care of their chronic lung patients. This was an exciting and very progressive move by Kingston since insurance providers reimburse for nurses to provide respiratory therapy,  and offer no additional benefits for the services of respiratory therapists. Because Kingston had to find the right balance between financial health with clinical quality, it was decided that the best way to achieve this would be to have respiratory therapists focus less time on providing routine care and focus their attention primarily on timely patient assessment, education, and the recommendation of evidenced-based care to their patients’ providers. After two years of building the program, KOM proudly boasted of having a zero percent return-to-hospital rate for their Chronic Obstructive Pulmonary Disease (COPD) patients for the first three quarters of 2016.

What follows is another example of the value of RTs focusing their critical thinking skills. After permitting their RTs to apply their critical thinking skills through respiratory therapist-driven protocols for their adult patient population, Marion General Hospital in Marion, Ohio saw a decrease in the average length of stay (ALOS) for their COPD population (4.37 in 2001 to 3.93 in 2002), as well as a significant drop in the ALOS for their patients receiving mechanical ventilation. This drop in ALOS not only reduced therapist-to-patient ratios but more importantly decreased their patients’ chances of suffering from further complications such Ventilator Acquired Pneumonia (VAP). From 2001 to 2004, MGH has had only one incident of VAP.

Strong technical skills will always be essential for RTs to be successful, but their assessment skills will be of greater value as their workloads shift from being less consumed by routine treatments to becoming more consultative in nature. As a result, respiratory therapists will want to focus on continuing their education in ways that will improve their ability to critically think; otherwise, those who are weak in this area may find it difficult to stay afloat in this new, fast-approaching healthcare market.

In Conclusion

Being only one member in a group of thousands may sometimes cause us to question if giving our best is really all that important in the whole scheme of things. It is during these times when we should recall the many ways in which Respiratory Care has been very good to us, our families, our teams, and the patients we serve. After all, where would Mr. Blue Bloater or Mrs. Pink Puffer be today if it was not for the RTs who serve on the frontlines of healthcare?

How then do we stay focused on making the most of our professions in uncertain times? We do it by acquiring the ability to balance between developing good critical thinking skills, focusing on providing good customer service, improving our quality of worklife, and being good financial stewards of resources. Focusing on all four of these essential components is the quickest way of achieving excellence both for ourselves and for our profession.

Preparing for the Future: Four Vital Strengths Respiratory Therapists Should Develop

The Future of Healthcare

It’s coming whether you like it or not, and it will be here sooner than you think. The “baby boomer” generation, born between 1946 and 1964, will arrive at the age of 65 between 2011 and 2029. The Center of Health Workforce Studies states: “Between 2000 and 2020, the U.S. population will add 19 million older adults. Overall, the numbers of older adults in this country will grow 138% in the next fifty years. By the year 2050, one of every five Americans will be age 65 or older.”1 This trend will have direct implications on the field of Respiratory Care due to the fact that respiratory therapists (RT) routinely see patients with chronic diseases that are disproportionately concentrated within the geriatric population. Combine these increased admission rates with growing RT vacancy rates and we have a serious crisis to solve.

1. The Strength of Adaptability

Due to factors such as declining reimbursement rates, rising costs of technology and increased competition between healthcare facilities driving up the cost of wages, healthcare as we now know it will have to change if it is to remain financially solvent. These changes will take their shape in the form of improved efficiencies in the way clinicians perform their duties and utilize technology. For example, we are currently witnessing the increased utilization of nurse practitioners to meet patient demands as physicians become more difficult to recruit. We are also seeing the skills of paramedics being utilized within emergency departments (ED) throughout the country as vacancy rates for registered nurses (RN) skyrocket.

Changes such as these will continue to occur as hospital administrators seek to invest in clinicians who can offer them the most “bang for their buck.” Respiratory therapists, therefore, will need to acquire and maintain strong, critical thinking skills in a variety of areas to remain in high demand and avoid having some of their key skills usurped by other professions. To adapt to these changes, RTs will need to be more diligent in asserting their skills and abilities that they are actually licensed to perform.

2. The Strength of Efficiency

The implementation of therapist-driven protocols will be vital in assuring that the best possible care is provided to cardiopulmonary patients in the coming years. Protocols will help establish credible paths in which non-pulmonary physicians and prescribing practitioners can confidently provide the best possible care for their pulmonary patients. The implementation of protocols, however, must be carried out with utmost attention. Respiratory managers should assure that physicians, RTs, and RNs are all appropriately solicited for what will work best at their particular hospital. It is also important that protocols are designed so as not to be reduced to mindless checkmarks, nor made so complex that they cannot be performed in a reasonable amount of time.

The efficient use of protocols in addition to the intelligent use of technology will also help stem the tide of overly difficult therapist workloads. According to my experience, there are nebulizers currently on the market that provide superior respirable doses2 and noticeably improved clinical outcomes3 to patients in only 3 to 5 minutes (e.g., VixOne; Westmed, Inc; Tuscon, Ariz.; and the Aeroeclipse; Monaghan Medical Corp; Plattsburgh, NY). Although they are more expensive, the time savings should allow RTs to focus more attention on the patients who truly need their services and thereby help decrease the overall average length of stay of pulmonary patients.

Since studies have proven that metered dose inhalers (MDI) are just as effective as hand-held nebulizers for the majority of patients who require aerosol therapy, it is also imperative to incorporate the transition from hand-held nebulizers to MDIs into the protocol mix.

3. The Strength of Marketability

As the years progress and technology expands, it will be very difficult for RTs to keep up to date with ever-expanding research and development within the sphere of respiratory therapy. It will, therefore, be important for the profession to implement processes for RTs to advance their knowledge and skills. Career ladders are strong tools that will provide a way for RTs to grow professionally and be rewarded for their efforts, while also providing an objective way for managers to attract and sustain high performers.

To be successful, however, career ladders must provide ways for RTs to advance professionally, and not just offer financial rewards to those who perform additional duties. Many competent RTs leave the profession because the field has not developed ways in which the most ambitious can advance in their careers. Thus, the profession will thrive best in an environment that has the ability to sustain its most tenured and talented experts as inexperienced new graduates enter the field.

The National Board for Respiratory Care has the ability to help rectify this problem by creating additional credentials that would assist RRTs in acquiring and maintaining the skills necessary to specialize in areas that will only continue to grow. Hypothetical credentials such as the RRT-CVS (Cardiovascular Specialist) could potentially lend credibility to allowing RRTs to administer cardiovascular agents during cardiac stress testing and assist in cardiac catheterizations, which are normally roles reserved strictly for RNs. Multitasking practices such as allowing RNs to refocus their expertise in procedures that only they are licensed to perform will result in improved efficiency without sacrificing quality.

4. The Strength of Education

As nurse practitioners and physician assistants are given more responsibility to assess and treat patients, it is imperative that RTs possess the appropriate levels of education necessary to develop and recommend the best care plans possible for their patients. The Committee on Accreditation for Respiratory Care can assist the profession in this arena by requiring accredited respiratory therapy educational programs to raise the RRT educational requirements to the baccalaureate level. Although this will add to the overall cost of healthcare on one end, on the other, it will save hospitals money long-term by allowing them to employ clinicians that can safely and efficiently multitask.

Although improving the educational requirements within the field of respiratory care is important, maintaining the associate-degree level certified respiratory therapist (CRT) credential will be vital to assuring there are appropriate numbers of therapists to provide fundamental respiratory care for all. There are many people who are considering a second career in healthcare. Understandably, many of these folks do not have the time and money to devote to four or more years of college. However, they do possess the skills necessary to effectively meet the mission of the respiratory care profession. CRTs who do not wish to advance to higher credentials should, therefore, be permitted to continue in assuring that vital technical duties are completed at their highest level.

Transitions described here will not occur until professional growth is actually possible. Moreover, this professional growth must offer the actual possibility to acquire higher levels of responsibility unavailable to those who do not possess the same level of training and education. As it currently stands, there is no difference in the educational requirements of a CRT and an RRT. Although there is a valid argument for adjusting the wage scale of an RRT slightly more than that of a CRT due to the objective demonstration of having the critical thinking skills necessary to pass the registry examinations, it is not fitting in most instances when both credentials routinely perform the same duties and require the same level of education.

These professional changes will only happen once pay scales match job descriptions, and job descriptions are differentiated according to education and credentials. But most of all, only managers possess the tools necessary to help make these changes, and they must take it seriously. Life for the respiratory therapy manager is going to be even more challenging within the coming years than it is already.