Respiratory Column

The practice of inpatient medical care is changing, and the role of home care has never been more important as a true partner in achieving continuity of care. Because so many hospitalized patients have respiratory diagnoses, the provision of comprehensive respiratory care in the home setting is essential in patient compliance and in avoiding the unnecessary hospital readmissions that can arise from non-compliance.

As a pulmonologist and a practicing hospitalist who works with hospitalist programs around the United States, I have observed a number of situations affecting home respiratory care that can promote or inhibit the patient's continued improvement or stabilization in the home. This article identifies these factors and outlines how elements of disease management can be incorporated into respiratory home care to improve outcomes and patient satisfaction.

Re-engineering the Health Care System

After several decades of cost containment mentality, the recognition that we as a society need to do more than "cut the fat" out of the system is growing. We need to re-engineer the ways that medicine is delivered - find ways to improve quality that also cost less than the current delivery system. Recognizing that most health care dollars are spent in the hospital, a new model of inpatient care delivery using physicians who specialize in inpatient care is rapidly becoming the standard for caring for hospitalized patients. These physicians, called hospitalists, can fully develop the level of clinical skills needed to manage the care for today's more intensely ill hospital patient. Having the physician available 24 hours a day, seven days a week in the hospital improves the efficiency of the patients' care by helping them move more quickly through the system and achieve better outcomes. Of critical importance is communication at discharge, both to the primary care physician who resumes the sup ervision of the patient and the home care team who will be coordinating care at home.

Once the patient leaves the hospital, he or she will continue to need a level of intensive management of care that typically does not occur in today's fragmented outpatient setting. A new model of home care, incorporating elements of disease management, is the answer to this dilemma - to deliver an improved level of patient care, higher patient satisfaction, fewer readmissions to the hospital, and enhanced compliance.

Home Care for Respiratory Patients: An Opportunity

Because respiratory ailments are one of the primary reasons why people are hospitalized, patients often require long-term assistance with complex equipment to manage their care. Respiratory conditions that pose the most concern for patients being released from the hospital and who are receiving home care are chronic obstructive pulmonary disease(COPD) and asthma. Together, these conditions afflict over 30 million Americans. Acute respiratory conditions (flu, cold, bronchitis, pneumonia) afflict over 130 Americans each year and can complicate the care of patients with non-respiratory diagnoses.

Studies show that respiratory home care is an outstanding, cost-effective alternative to inpatient care.

    • A 1991 Lewin/ ICF economic analysis that focused on the effect of the availability of home medical equipment services on the cost of care for patients in COPD determined that over $48 million a year could be saved through the availability of home equipment.
    • A recent Gallup survey showed potential savings of over $9 million a day on ventilator patients through the use of home versus inpatient care.
    • A 1982 study sponsored by former Surgeon General Koop showed (potential) savings to respirator dependent children of more than $15,000 per patient per month.
    • An Aetna Life and Casualty study showed savings potential of between 41.9 percent and 87.8 percent for home care over hospital care depending upon the specific respiratory illness.

The overwhelming conclusion is that home care and the availability of the proper home equipment have the potential to save our healthcare system enormous resources on respiratory illnesses and contribute to patient outcomes and stabilization.

Currently, however, home care companies offer few, if any, services to assist the respiratory patient other than the delivery of the needed equipment. Little training or customer service is performed. Patient follow-up to track compliance and satisfaction is virtually non-existent. The result is a respiratory care service that is not satisfying patients, not contributing to wellness, and not improving outcomes and health care costs for the community or the local managed care plans to the degree that it could and should.

Why are home care services for respiratory patients less than optimal? There are two primary reasons. First, many physicians and hospital staff members are not aware that patients can go home with complex respiratory equipment including ventilators. In a recent case, an 11-year-old boy who was a quadriplegic had been hospitalized for three months. Through an educational process, the hospital team learned of a laptop-sized ventilator that could provide the pressure control and pressure support that the patient required. He was not only able to return home with this equipment but also he could resume school. He and his family were thrilled for him to be home. And the costs of inpatient care - which can average $5,000 a day - were avoided. Clearly, education on home care options for these patients is critical to making the best choices for their long-term health maintenance.

Second, most companies providing home care are generalists. They provide home care for all diagnoses. Equipment companies offer the purchase or lease of respiratory equipment only. There is little if any reimbursement for education or for patient follow-up and monitoring, so these services tend not to be performed. Home care agencies providing nursing support in the home train their staff to provide day-to-day care for the patient, not to manage the case long term with an eye on avoiding readmissions, anticipating changes in health status, and communicating effectively with the other members of the health care team.

A New Approach

A new approach to home care respiratory services combines home care with disease management for a more patient-centered process. The existence and use of disease management companies and techniques is still quite new. Disease management companies attempt to improve outcomes and cost through the assurance of appropriate care and patient compliance to prescribed treatment patterns. These companies monitor overutilization of services that cause unnecessary costs and underutilization of services that could cause greater health care expenditures. The goal of a disease management company is to ensure appropriate treatment and promote healthy behavior among a specific patient population while lowering overall health care costs for that group. Disease management is, therefore, population based and disease based. It is, in part, the introduction of the disease management concept through the hospitalist that has made the hospitalist so effective in improving the management of the inpatient experience. The same concept can be applied to home care, with similar improved results.

The confluence of these two industries, home care services and disease management, create a significant opportunity to improve respiratory care in the home setting. Both home care services and disease management achieve their savings while simultaneously increasing services to patients and potentially improving patients' health status.

Disease management approaches to population have recently demonstrated savings potential. A pilot program of care in cardiovascular disease by Brown and Tolland showed savings of $2 for every $1 invested in the program, improving the use of hospital days by 38 percent while receiving excellent satisfaction marks from patients. Blue Cross of California undertook a pilot program in asthma management that resulted in inpatient day savings of 11 percent and emergency room usage savings of 12 percent.

The time is right to deploy a disease management approach combined with a delivery, tracking, training and follow-up service to improve the quality and cost-effectiveness of care for patients with severe chronic respiratory diseases.

What does this confluence look like? Home care will incorporate more appropriate training of individuals who use the equipment at home. Each delivery should have two components: delivery/set up and teaching. The service technician or the respiratory therapist, depending upon the complexity of the case, conducts the teaching component. Proper teaching sets up proper compliance and proper care and will improve patient health status. The steps in this process include:

    • Regular contact and monitoring of patient compliance based upon need to improve patient health status, avoid health deterioration that causes readmissions, and improve patient satisfaction and lifestyle.
    • Switch-out of equipment when advances in the equipment technology can improve outcomes.
    • Contact with respiratory therapists in situations where such contact can aid in the avoidance of inappropriate emergency room visits.
    • Close tracking of equipment and patients to ensure the right equipment is being used by the patient and that it is based upon their current need.
    • Pick-up of unused or inappropriate equipment to save money for payers.

Follow-up to the original delivery and teaching appointment is patient and illness dependent and should be tracked by an information system that can ensure appropriateness. Follow-up normally consists of equipment maintenance and patient contact. The equipment should be monitored to ensure compliance with manufacturers' specifications and requirements, and this monitoring should be tracked by the same information system. This can be accomplished by regular (usually quarterly) maintenance checks. These checks should be conducted by physically touching the equipment, not by a telephone call. The checks should cost the patient and the payer nothing, and they should provide multiple assurances, including: the equipment is in clean and working order; the equipment is the most appropriate for the needs of the patient; and the equipment is still required for the illness of the patient. Together, these elements ensure the patient and the payer the utmost in appropriateness and consistency.

Patient compliance and care can be done through a telephonic case management approach on all patients who have high tech equipment. This intervention can consist of short, non-intrusive structured dialogues between the non-clinical case manager and the patient. The purpose is to gather information regarding medical condition, status and compliance. The calls should occur every two weeks.

The case managers identify any problems associated with equipment maintenance and supplies that many times go unnoticed, yet impact the patient adversely. The goal is to provide meticulous maintenance on equipment and supplies, significantly decreasing home infection rates, emergency room visits and hospital readmission. The case managers insure that all required maintenance and monitoring takes place using standardized and systematic protocols.

These case managers can be non-clinical in order to be as cost effective as possible. Most calls result in no new action or intervention needed. Therefore, it would be wasteful to use higher-cost clinical employees for the program. The case managers are specifically trained to turn the case over to a respiratory therapist should any abnormal or negative medical feedback be present. Because they are not clinically trained, the telephonic case managers are not tempted to advise or treat over the telephone. This helps make the process as cost effective as possible, while ensuring that only clinically trained employees are involved in care decisions and treatment.

Together with the tracking and measurement capabilities of the systems, these operational programs deliver the services and products in a professional and effective manner. They will contribute to satisfied customers, more referrals and greater overall results.

How is such an approach possible, given that these follow-up, disease management and case management services are not reimbursed? First, it is likely that continued pressure will come from payers - including state and federal governments - for home care providers to deliver better and more comprehensive services. To remain competitive, firms will have to incorporate these services to demonstrate improved outcomes and patient satisfaction. Second, it makes good business sense in today's health care environment. Most patients who require this type of equipment need it for long-term chronic ailments. The disease processes affecting these patients are normally not "cured" but only controlled at best. For this reason most of this equipment has no "cap" by payers. That is, unlike certain other pieces of durable medical equipment, the payment for this equipment continues long term, in order to match the need of the patients. New patients provide additional or increased revenue to the company, not simply replaced revenue for patients who come and go. Revenue decreases only come from one of the following events: patient dissatisfaction, patient death, and patients changing payers. An effective program can decrease the likelihood of all of these events.

Improved services and contracting with payers results in less downside revenue risk since better service lowers patient switching due to dissatisfaction. Better service also lowers mortality rates and increases the company's ability to maintain the equipment contract even in the case of a payer switch by the patient.

The time is right for the introduction of a disease management approach to home care for respiratory patients. The results will be increased patient satisfaction, better patient care and lower overall costs. When combined with a properly structured hospitalist program, this approach appropriately manages both inpatient and outpatient care of respiratory patients.

Cogent Healthcare, a hospitalist organization, has recently partnered with a San Antonio, Texas, respiratory company to jointly open new markets in several states. The systems these two entities have put in place are effectively identifying and monitoring high risk respiratory patients to help improve their care, along with decreasing emergency room visits and readmissions. Similar partnerships are anticipated with other disease management entities to help us improve the effectiveness of our hospitalist programs.

Ronald Greeno, MD, is a pulmonologists and practicing hospitalist in Los Angeles, Calif. He is a co-founder of Cogent Healthcare Inc. and the National Medical Director of Respiratory Solutions, a Texas-based provider of respiratory care to patients at home. He also is co-director of Respiratory Medicine at Good Samaritan Hospital in Los Angeles. He can reached at 949-699-6003, or at

This article originally appeared in the July 2000 issue of HME Business.


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