Vol. 20 •Issue 7 • Page 28
Home Care
Challenges of Home Ventilator Management
Mechanical ventilation is commonly prescribed for patients in home care, yet challenges with coordination of care, reimbursement and long-term management plague home care providers.
The National Association for Medical Direction of Respiratory Care (NAMDRC) facilitated an invitation-only consensus conference in 2004 to address the issues associated with managing the patient through the continuum of care.
This event included only the crme de la crme in pulmonary medicine, allied health care and manufacturing. The goals were simple and ambitious: explore current mechanical ventilation issues involving reimbursement, transition to lower levels of care and discharge to home and propose solutions.
Early in the meeting, it became clear that the topics would be addressed but not in great detail for home care providers. So when my turn to speak came, I made the most of my time presenting the case for home care by outlining issues associated with discharge planning: establishing the patient in a safe environment, ensuring the home ventilator’s effectiveness on the patient prior to discharge, training caregivers, verifying appropriate reimbursement and instituting a plan of care supportive of caregivers.
Home care providers must participate in a team conference or discharge planning for the patient prior to discharge. This typically occurs at an acute care facility (hospital), long-term acute care facility (LTAC) or sub-acute facility or skilled nursing facility (SNF).
Conferences should include the discharge planner, case manager or social worker, primary care or pulmonary physician, the patient (if possible), family, caregivers and home health agency (if involved). The purpose is to ensure coordination of care and clearly define goals, roles and responsibilities. The home care provider must identify the primary caregivers and support their training on the operation of the ventilator that will be used in the home.
The type of ventilator must be well-established as safe and effective to support the settings required for the patient. It needs to be used on the patient in a controlled environment to establish tolerance, effectiveness of the ventilator and competence of the family and caregivers to operate the ventilator.
In addition, the home environment must be assessed and established as safe for the patient and supportive of the mechanical ventilator’s use with a grounded electrical power source. The home must be relatively close to the home care provider’s clinical operations and community emergency services in the event of ventilator or power failure.
Careful coordination must also include planned dates and times for delivery of equipment, supplies, transportation of the patient to home and caregiver assignments or schedules. The family must be provided with instruction on suctioning, use of the ambu-bag in the event of ventilator failure, cleaning and disinfecting equipment and tracheostomy care.
Infection control is important, and the caregivers and family (who are typically not health care workers) must be educated and demonstrate competence with hand hygiene, cleaning equipment and changing supplies based on a frequency that is appropriate for the home care environment.
In many cases, home care providers place a secondary vent in the home to support the patient’s needs for transportation outside of the home or for use as a back-up in the event of primary ventilator failure.
Many patients ultimately exhaust their insurance benefits (or coverage). That is why it is important that reimbursement discussions include alternative sources to support ongoing supply needs once the ventilator is purchased. In addition, the home care provider must make an effort to obtain payment for the secondary ventilator at an agreed upon rate with the payor or family.
Home care providers should not overlook the need for sufficient reimbursement until problems with coverage arises after the patient has been discharged home. Although reimbursement is a difficult discussion for the respiratory therapist (typically focused on the clinical aspects of care) involved in the team conference, it is a topic that must be clearly addressed. That way the family, caregivers, physician and others don’t wrongly conclude that the home care provider failed to own up to the responsibility to support the care of the patient when reimbursement issues occur.
Many home care providers opt not to provide mechanical ventilation, supplies or services because of the poor profit margins as a result of the labor intensive resources required and lack of sufficient reimbursement. However, as the acute care shift continues and the trends with patients transitioning to the home for their chronic care needs, the reimbursement issues may hopefully change.
Certainly the challenges with transitioning patients are not insurmountable, but they must be proactively addressed by the home care provider in order to ensure a smooth and safe transition for patients who are discharged home for prolonged mechanical ventilation.
For more information or for guidelines on transitioning patients who require prolonged mechanical ventilation to their home, visit the American Association for Respiratory Care (AARC) Web site at www.aarc.org And click on the Clinical Practice Guideline on Discharge Planning for the Respiratory Care Patient.
Vernon R Pertelle, MBA, RRT, is senior director/assistant vice president for Tri-City Healthcare District, Home Care, Occupational Health & Wellness and Rehabilitation Services. He can be reached at [email protected].
