Home Care Has Changed Considerably Since Yesterday

Home Care Has Changed Considerably Since Yesterday

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Home Care Has Changed Considerably Since Yesterday


Times have really changed since those days of yore when home care was limited and specialized. For COPD patients, home care often centered on durable medical equipment (DME) company staff basically leaving H-cylinders of oxygen in a patient’s home. In many ways, the 1980s were the golden age for respiratory therapists involved in home care because substantial profits could be garnered by providing home oxygen.

But that was the past. Today, reimbursement strategies have evolved to become much more strict and at levels far lower than those existing a decade ago. At the same time, home care includes many other patient groups and the care is far more specialized for each group.

It is not difficult to understand the reasons for the changes. Health care is expensive, especially care delivered in an acute care setting. It is cheaper to deliver care in an alternate setting. Anyone who has worked in the medical field in any capacity for any length of time has felt the impact of the changes taking place as third-party payers scramble to cut the cost of providing medical care.

In the past, third-party payers were traditionally Medicare or broad-based private insurance plans like Blue Cross. But those plans have given way to newer managed care reimbursement systems like HMOs and Medicare-paid provider systems.

Changes In Care
Eight or 10 years ago, it was common for respiratory-challenged patients to periodically spend five to 10 days at a time in an acute care hospitals where clinicians treated their recurring dyspneic spells and upper respiratory infections. Treatments and length of hospital stay were reviewed by an in-hospital department, and without too much difficulty and general red tape, the care would be approved for reimbursement.

Fast forward to the current time and some major changes have occurred. First, it is not as easy to get admitted to a hospital; second, third-party payers are more selective as to treatment options for which they are willing to pay. Due to flagrant abuses of services and overbilling for such care over the years, Medicare began to tighten its scrutiny. Since many insurance providers follow Medicare’s example, their authorization for payments also became more strict.

In the process, one clear trend emerged: more care was transferred from acute care hospitals to alternate settings like home care. Two major concepts have impacted such care, making it possible. First are the advances in medications being used to treat various diseases. Second is the incredible advancement in technology available.

Changes In Procedures
In the shuffle, the care of respiratory-challenged patients has changed dramatically. As recently as five years ago, the home health care provider network was plentiful, with several thousand small medical equipment/oxygen providers caring typically for 75 to 100 oxgen patients each. These smaller companies were intrinsically focused on providing a high level of patient care.

By and large, the companies did an excellent job of providing optimal patient care. Most turned a profit for their owner-operators. But with the changes in payment for services rendered over the years, less money was available to the DMEs, impacting both quality and quantity of service.

From 1996, when the first major cuts by Medicare for home oxygen were enacted, to the current day, an increasing number of companies began to suffer financially. The result has been mergers with larger firms or cessation of operations altogether.

DMEs remaining in operation are charged with the task of providing efficient, optimal patient care in a quickly changing market. Regardless of the size of the operation, the following optimal care standards must still be maintained:

Standards Of Care
1-Monthly concentrator/equipment checks. These checks, though time-consuming and costly, are needed to monitor equipment reliability and to stress to patients the importance of machine maintenance. Any RT who has done home care for any period of time has multiple tales to recite of machine misuse. The checks help ensure the equipment is kept away from hazards and unused cylinders are stored safely.

2-Regular RT visits. Caregivers should routinely see their patients at least every four to six months. Post-hospitalization and requested visits are performed at random intervals. The primary reason for routine follow-up calls is to monitor patient compliance with physician orders and to update any changes in the Plan of Care. Even months after initial set-ups, patients may have questions concerning various aspects of care they are receiving. Many companies like ours also provide a number of handouts explaining the nature of the person’s illness and the benefits of the treatments they are receiving, so the visits provide an opportunity to review that material.

3-Nebulizer therapy visits. This group has some distinct needs. Many patients are prescribed nebulizer therapy long before they get oxygen therapy. Some will not need oxygen support for years, depending on the stage of their disease and the compliance with doctor-ordered aerosol therapy. Companies should monitor medication compliance, even if the checks are nothing more than a telephone follow-up. Any follow-up encourages patient compliance with medication use and can uplift patients who live alone with a few brief moments of conversation. In the long run, we have found that regular patient compliance with ordered medication use leads to a higher level of physical activity and greater freedom from the impact of the disease than the patients would otherwise have.

4-Plan of Care Maintenance. An ongoing challenge caregivers face daily is updating the plan of care. Each patient file should contain a plan of care. This is per JCAHO guidelines for the clinical respiratory provider. A care plan is just what the term implies, an outline of the treatment rendered and what changes in medication or oxygen liter flow occurred and what equipment was installed or discontinued. Care plans provide accurate accounting of what has been done for the patient and serve as a valuable protection device from a legal view. Basically, if something is not written down, it did not happen.

5-Connection with pulmonary rehab programs. Since treatment of breathing-impaired patients, especially COPD patients, is prevalent in home care setting, it should only follow that access to a rehab facility would only enhance home care treatment. Patient involvement in rehab programs is generally a love/hate relationship. Patients, after exposure to such programs, are either committed to improving their physical abilities or have vowed never to return. Bottom line? Patients who do take the time and energy to stay active in a controlled program are generally happier and more positive concerning their disease.

Visions For The Future
Attention to detail is vital to maintaining a sound financial bottom line. Word spreads about those who provide optimal care and this brings in added patients. As one of our upper level administrators recently said, “Take good care of the patient, and the numbers will be there.”

One of the nation’s automakers has spent millions of dollars promoting its slogan: “Quality is Job #1.” Obviously, due to copyright laws, RTs cannot openly copy the slogan on lapel pins and signs. But we sure can carry the theme internally. Despite all the changes over the years, the one constant in the home care equation remains unchanged: dedicated people working with the ill. Home care. You got to love it!

Michael Vlasic is affiliated with Hooks’ Oxygen and Medical Equipment, a home care provider in Dayton, Ohio.