Over the past 10 years, some respiratory therapists (RTs) have embraced the notion that it is acceptable to hand off certain respiratory care modalities to other allied health professionals, or worse, to relatively unskilled labor. The rationales range from, “we should be ventilator specialists,” to “the cost to perform the therapy is greater than the reimbursement.” These are not outdated therapeutic modalities that are replaced by better approaches or no longer in use. Rather, these are respiratory therapies that are still of value to patient care, but are now being delivered by non-respiratory personnel in some hospitals and post-acute settings.
RTs as Physician Extenders
As the medical equipment and technical experts of the healthcare profession, respiratory therapists are ideally suited to be cross-trained for any care that can be rendered by a non-physician. In the new American healthcare system, clinicians will be in high demand if they can take on diverse responsibilities, demonstrate valuable health outcomes, and do so more cost-effectively than anyone else does. To this end, respiratory therapists should focus on achieving recognition as the physician extenders that they were trained to be. However, before anyone will successfully brand the profession as the most capable of taking on newer, more challenging responsibilities, RTs must first demonstrate their expert management of the entire array of respiratory services currently within their purview. Why would anyone consider respiratory therapists for more rigorous work if they seem unable, or unwilling, to handle what they already have?
Respiratory therapists should be accumulating responsibility and oversight for a growing list of services. Until recently, however, RTs seemed determined to downsize their scope of practice and pigeonhole themselves as “vent jockeys.” Even more destructive to the profession are respiratory therapists who rush to get their work done, after which they sequester themselves away in the respiratory break room. So what will it take to reverse this self-destructive trajectory?
A Paradigm Shift to Value and Outcomes
Respiratory therapists must first begin by doing away with the notion that some respiratory modalities are not important or lack value. If an evidence-based therapeutic modality still has value to physicians and insurance companies, and if implementing that modality contributes to a health-enhancing and cost-effective outcome for the patient, then respiratory therapists should see it as a valuable service. For example, incentive spirometry is important to maximize lung volumes and prevent post-operative atelectasis and its complications, especially pneumonia. Why entrust such an effective, low-cost modality to clinicians not trained in lung function, hyperinflation therapy, and pulmonary pathophysiology? In terms of patient satisfaction, when the therapist properly emphasizes the importance of even “minor” respiratory modalities, patients will respond in kind. Therapists can attest to this if they have ever visited a patient’s home post-discharge, and witnessed him or her proudly demonstrate mastery of their I.S. technique.
Reimbursement should not be used as the excuse for “giving away the farm.” First, most respiratory therapists earn less than experienced nurses do, yet theirs is the profession to which RTs are giving away responsibilities. Second, respiratory therapists could take a page from the pulmonary rehabilitation playbook: Despite the fact that pulmonary rehab reimbursement is low, smart program developers find ways to make it work by bundling services together and combining nonpaying services with reimbursable services. Pulmonary rehab successfully provides patients with the self-management tools they need to stay out of the hospital. It has taken decades for pulmonary rehabilitation professionals to prove the value of their services to hospital administrators and insurance payers, but their hard work has finally paid off. Medicare is now gradually increasing the reimbursement for pulmonary rehab, and is asking program managers for supporting documentation to warrant further increases. Pulmonary rehab is here to stay, and the respiratory profession should be taking notes.
Respiratory therapists should be required to stay visible to the other members of their team at all times. The “team” includes doctors, nurses, and other clinicians with whom respiratory therapists care for patients. Therapists should not be allowed to leave their stations unless they are scheduled for a break. As one therapist said, “The days of first round treatments followed by breakfast have to go. Challenging docs to discontinue passive, pointless therapy has to be the norm.” Therapists will not be available to demonstrate their high value to the healthcare team unless they are actively looking for ways to deliver superior, cost-effective patient care. They should solicit referrals from nurses for patients who need respiratory consults. They should be consulting every day with physicians, their assistants, and nurse practitioners. They must be engaged at the moment a crisis occurs, or when things in the unit or on the floor get suddenly busy. Even when there is not a crisis, RTs should be available to assist their fellow teammates whenever they need help. While the best therapists already practice respiratory care in this manner, it is time to raise the bar for the entire profession.
Lowering Costs While Elevating the Profession
Recently, California enacted a new law that eliminates the CRTT credential and replaces it with the RRT credential as the minimum requirement for licensure. The nation as a whole is embracing the notion of a Bachelor’s degree as the minimum educational requirement for respiratory therapists. Will this raise the cost of hiring respiratory therapists? Will it become too expensive to hire RTs outside of the ICUs? Here are a couple of suggestions: Hire new graduates to do patient education and floor care, and stop putting them directly into the ICUs. This will give them a chance to get oriented to the job without getting in over their heads. It will allow them to polish their skills as patient self-management educators, a skill that is highly valuable now that hospitals are incentivized to prevent hospital readmissions.
It is critically important to stop minimizing the work of therapists who actually enjoy the rewards of floor care, subacute care, rehabilitation, and home care. Respiratory therapists need to recognize the important places these RTs occupy in getting patients healthy and keeping costs low. Their services are highly valuable to patients and insurance companies alike, and will only become more valuable in the future.
Carpe Diem
The biggest paradigm shift for respiratory therapists is in how the profession perceives its important role on the healthcare stage. Ideally trained as consultants and physician extenders, respiratory therapists are members of a growing community of healthcare providers. Respiratory therapists should assume a leadership role, and now is the time to step up. Too many respiratory therapists are dismayed and concerned about the future of their profession. Instead, therapists should embrace their extraordinary skill set, and, through a passion for excellence and willingness to serve, demonstrate a model of value for the enduring health and well-being of those in their care.
Victoria Florentine is president and founder, Select Respiratory Services.
References
- American Association for Cardiovascular and Pulmonary Rehabilitation. Pulmonary rehabilitation toolkit: guidance to calculating appropriate charges for G0424. Available at: www.aacvpr.org/Portals/0/policy/PRReimbursementToolkitFINAL.pdf.
- California Respiratory Care Board. RRT established as minimum requirement for licensure. Available at: www.rcb.ca.gov/forms_pubs/rrt_requirement_info.pdf
- Center for Outcomes Research and Evaluation. CMS Medicare hospital quality chartbook: performance report on Outcome 2013. Yale New Haven Health Services Corporation.
- Kellar K. (2014). Discussion group. LinkedIn.
- Quality.Net. (2013). CMS national dry run: chronic obstructive pulmonary disease (COPD) 30-day mortality and readmission measures.
