Below is a letter penned by Sue, Dave, and partly, myself to state representatives from Ohio regarding HB 49:
We are very disappointed that the House leadership has chosen to ignore the opponent testimony and calls from our professional association (Ohio Society for Respiratory Care) when crafting Sub. HB 49.
Sub. HB 49 abolishes the Ohio Respiratory Care Board (ORCB) and replaces it with an advisory council under the Ohio Medical Board. We request that the ORCB budget be restored to full funding for both FY 2018 and 2019, and that it remain an independent board so that it can continue to provide meaningful regulation of respiratory care professionals (RCP’s) and protection of the public.
RCPs undergo extensive education and training in the assessment and treatment of respiratory and cardiac diseases. In fact, Registered Respiratory Therapists (RRTs)—those RCPs who have passed both a rigorous written and clinical simulation examination—have a well-defined scope of practice and have been identified by the Medical Board of the National Academy of Sciences as Type B Physician Assistants. Type B Physician Assistants are expected to have more knowledge about their medical specialty than the average physician who is not board certified in that area. This has allowed RRTs to be considered the authorities in the operation of life-support equipment used in critical care areas, such as intensive care units and trauma centers. The application of mechanical ventilation for critically ill patients in respiratory failure, such as babies with heart conditions, places an immense demand for continual training of RRTs. Furthermore, their critical thinking skills, coupled with an in-depth knowledge of the vast array of cardiopulmonary diseases, has allowed them to remain the go-to experts for assessing and recommending the appropriate therapies to non-physician providers, such as nurse practitioners.
As the number of licensed physicians continue to decline in the State of Ohio, protecting the quality of the profession that best compliments the growing demand for nurse practitioners and physician assistants in the assessment and treatment of cardiopulmonary disease is vital. Moreover, as return-to-hospital rates for Chronic Obstructive Pulmonary Disease (COPD), congestive heart failure (CHF), and pneumonia continue to cause heavy stress on the financial health of Ohio hospitals, protecting the quality of the profession that can best assist providers in the management of these diseases is crucial in protecting the health of the public and reducing healthcare costs.
If this bill passes, RCP’s may not have the appropriate level of representation on the Medical Board who will be regulating the profession. The current language only states the Medical Board will appoint respiratory care advisory council and “to make initial appointments” of “not more than 7 individuals knowledgeable in the area of respiratory care. There is also no requirement for the council to actually meet and no mention of authority or responsibility to make re-appointments after the initial assignments – so it appears that the advisory council could disappear after the first 3 years of existence.
The language requiring meaningful qualifications for education, training, license or actual practice experience in pulmonary medicine or respiratory care for the proposed advisory council members has been removed.
The Medical Board is made up exclusively of physicians and consumer members who will be hearing RCP disciplinary cases and deciding their outcome. The OSRC strongly feels that RCP licensees will be at a significant disadvantage when they appear before the board of doctors and public members who only have limited knowledge of the RCP’s scope of practice, education and procedures.
The OSRC is very concerned that merging the ORCB function under the Medical Board may reduce the efficiency of the ORCB staff in processing licenses, particularly without an Executive Director to specifically oversee and manage the ORCB operation. Current timeliness of ORCB response to requests and licensing is excellent.
The ORCB is fully funded by its licensee’s fees. Where is the value in this merger when current expenses are covered by the licensees who lose effectiveness professional regulation? This is taxation without representation.
I want to thank Sue and Dave of the legislative committee for the work they’ve been putting into this endeavor to stop the language of HB49 that will place us under the Ohio State Medical Board. Please forward this important information to those within your individual networks, especially department directors who have influence over a large number of RCPs within the state. It’s important that we make as many people aware as possible, and ask them to contact their legislators. We fully expect to beat this; but if by chance this passes, at least we will be able to demonstrate to our state RCPs we did our best to stop it, and that their help with future issues is absolutely necessary.
Respiratory Care Jan 2017, 62 (1) 1-9; DOI: 10.4187/respcare.05030
BACKGROUND: Patients with COPD often require repeated emergency department visits and hospitalizations for COPD exacerbations. Such readmissions increase health-care costs and expose COPD patients to the added risks of nosocomial infections and increased mortality.
METHODS: To determine whether a respiratory therapist (RT) disease management program could reduce re-hospitalization and emergency department visits, a prospective, single-center, unblinded, randomized trial was performed.
RESULTS: We enrolled 428 subjects (214 intervention, 214 control). The primary outcome (combined non-hospitalized emergency department visits and hospital readmissions for a COPD exacerbation during the 6-month follow-up) was similar for the study groups (91 vs 159, P = .08). When the 2 components of the primary end point were analyzed individually, the percentage of subjects with non-hospitalized emergency department visits for COPD exacerbations was similar between groups (15.0% vs 15.9%, P = .79). Readmission for a COPD exacerbation was significantly lower in the intervention group (20.1% vs 28.5%, P = .042). The median (interquartile range) duration of hospitalization for a COPD exacerbation was less for the intervention group (5 [3–11] d vs 8 [4–18.5] d, P = .045). In-patient hospital days (306 d vs 523 d, P = .02) and ICU days (17 d vs 53 d, P = .02) due to COPD exacerbations were significantly less for the intervention group. Mortality was similar for both groups (1.4% vs 0.9%, P > .99).
CONCLUSIONS: Our RT disease management program was associated with less readmission, fewer ICU days, and shorter hospital stays due to COPD exacerbations. Further studies are needed to determine the optimal utilization of RT disease management teams for patients with COPD to optimize outcomes and prevent return hospital visits. (ClinicalTrials.gov registration NCT01543217.)
It only makes sense that employing clinicians with specialized training in respiratory disease management to improve the outcomes of patients with lung disease is the best route to take in achieving this goal. This study should be in the back pocket of those in positions of influence within the respiratory care world. Because decision makers are busy people who are constantly being bombarded with a myriad of fires to put out, we as respiratory care professionals need to be able to quickly back the value of our abilities with convincing data.
Respiratory therapists (RT) will be most valuable over the next decade utilizing their assessment and care planning skills in areas where we have not historically existed in significance. Areas like skilled nursing and case management are just two such areas. It will be hard to break into skilled nursing, however, until the reimbursement structure for this environment pays the owners of these companies for providing respiratory care only by those who hold a respiratory therapy credential. This won’t happen until we RTs utilize data such as this en masse in our lobbying efforts.
In the short run, just be vocal about the value you bring to the clinical team, and be able to back it up with evidenced-based data. The more of us who offer smart solutions to difficult challenges, the more we will be sought after to solve such dilemmas.
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:
Therapy can be adjusted more frequently in response to changes in the patient’s condition;
Physicians are consulted for major clinical changes but not minor ones so nuisance calls can be avoided;
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
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 (medicare.gov/hospitalcompare/data/30daymeasure.html). 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%
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.
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.
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.