The RT Advantage

Why Now Might Be the Time to Bring a Therapist on Staff

If home care had a mantra, it might be that customer service unlocks doors. Any self-respecting provider knows that the service component can make or break a respiratory business. Good service gives respiratory providers a leg up on competition, while poor service can cause a business to shut its doors.

For HME to work, providers must establish trust with their clients. After all, staff members go into clients’ homes to deliver equipment. Respiratory therapists perform many duties that help providers establish trust, but they also do much more. An RT might help unlock other doors — with both referral sources and the community.

Listen to the stories of these respiratory providers to learn how bringing an RT onboard has helped strengthen their business models.

CARE Medical & Rehabilitation Equipment

Charging Ahead: Pacific Northwest Provider Adds RTs to Expand Respiratory Business
While other providers might be reducing the number of respiratory therapists on staff amid the onslaught of reimbursement cuts, CARE Medical & Rehabilitation Equipment, headquartered in Portland, Ore., is increasing its staff. According to Vice President of Operations Angelene Adler, the main reason is because the company is adding a respiratory component to new branches and some of its old branches.

With 11 branches in Oregon and Washington, this busy company certainly needs the help of RTs to stay on track.

“We’re adding a whole different product category on,” says Adler. “We have to have the staff to be able to service the client, to train our staff on an ongoing basis, to market, to let the community know that we’re providing new types of respiratory modalities in the communities we serve.”

Pulse on the Market
One of the advantages of being an independent provider is the ability to respond quickly to market changes. Respiratory therapists help CARE stay on track with those market demands.

Adler says RTs in the field know what the demand is and if there’s a certain area that’s demanding certain types and brands of equipment. They also know what referral sources prefer. Having that inside knowledge has helped CARE adjust its inventory to stay viable in the marketplace.

“Our therapists help find out what our market segments need and relay that back so that we can meet that need,” says Ted Welker, RRT, respiratory home care consultant. “We find out what they want and then we try and address that need.”

The provider must also adjust to the varying needs of the local community, which may mean carrying different respiratory equipment in different branches.

“You’ve got maybe this doctor over here in this county at this branch location that only wants this, and then you have another doctor or respiratory therapist at a sleep lab or something and they want that,” says Adler. “We can do that. We’re not just stuck to having to carry this model of this brand at all of our branch locations. We can service what the community is asking for, whether it be the referral source or the client.”

The feedback CARE gets from RTs enabled CARE to expand its portable oxygen business. “The competitors don’t offer the new types of modalities — like for portable respiratory oxygen — and we’re bringing those into the marketplace,” says Adler.

The company has even worked with The MED Group on an O2 Travel Guide that can be distributed to travel agencies, airlines and clients to get them ready to take flight.

For RTs to help make equipment decisions, they must know equipment inside and out. That is especially true in today’s reimbursement marketplace.

“We’ve tried to train the entire clinical staff on proper selection of equipment that meets the customer’s needs so that we’re not doing a lot of downstream shuffling of equipment,” says Welker.

With the 36-month cap on oxygen, it makes good business sense that clients keep the same equipment throughout the rental term.

“We’re trying to make sure that the clinicians have all the tools that they need, including equipment, (and) knowledge base as well to make the right selection the first time,” says Welker.

Addressing Client Needs
At CARE, it’s not unusual for clients to ask for RTs by name. In fact, the relationship between RT and client often develops into a friendship.

“Some customers will choose one clinician and bond with them,” says Welker. “If they don’t happen to be on duty that day, they’ll call back and leave a message because that’s the person they rely on for information.”

That’s not to say other RTs at the location aren’t capable of answering the client’s question. CARE strives to provide consistent information flow so that all staff members are armed with the same details to pass along to customers through e-conferences and respiratory summits where all of their staff is in the room at the same time.

The RT-client relationship is vital to ensuring compliance. Trust comes through the information the RT is able to provide. Welker says that often a client comes in, especially for CPAP, and may not understand the equipment or that the therapy might be life-long. RTs must step in to provide that information.

“Often the respiratory therapist is looked at as a resource for information because many of us — when it comes to equipment — are very detail oriented,” says Welker. “We know some of the idiosyncrasies and the pluses and minuses of various pieces of equipment.”

Aggressive follow up on treatment, especially with CPAP, helps ensure the patient gets the most out of therapy. At CARE, RTs follow up with CPAP and bi-level users within the first five to 10 days, again a month later and then every three to six months after that to drive compliance.

“What we’re trying to do is tailor a program that meets the customers’ needs and helps them through that initial 14 days to a month where their acceptance of the therapy is critical,” says Welker. “Because otherwise we lose them, and then they’re subject to congestive heart failure and high blood pressure and diabetes and strokes and heart attacks or falling asleep at the wheel on the same highway that you’re driving on.”

Part of that compliance program includes looping in physicians and referral sources to the status of the patient. According to Welker, RTs download memory from machines with that technology and provide doctors with indexes that show how the patient and machine are getting along.

“It’s very involved and very time consuming, but the outcomes can be very positive and rewarding,” he says.

RTs at CARE also participate in local support groups to direct the patient’s path, even if those patients are not their own. Some of the support groups they attend include the Better Breathers Club, sponsored by the American Lung Association, and A.W.A.K.E. groups. Welker jokes that often patients choose to become their customers simply because of the care the RTs have shown.

Lessening the Load
“Every day is so different,” says Welker. “Often you’ll walk into the office and not quite know what to expect. You have a list of patients who need to be contacted, whether they’re on a ventilator and we need to do a ventilator check at their location; whether it’s somebody coming in bringing their CPAP machine because they’re having difficulty with their mask; and in between you may get a call to go out and show someone how to use an oximeter for overnight oximetry because a doctor wants to check and see how someone’s oxygen therapy is going.”

With all of these different responsibilities, sometimes the RTs workload can get a bit challenging. To help lessen the load, CARE also employs respiratory assistants, or customer service representatives with special respiratory training to take orders, make sure equipment is coded properly for delivery and complete some of the paperwork.
These assistants are also trained to fit CPAP masks, process orders through insurance and understand sleep studies.

Welker says time management is always a challenge for RTs, given the many nuances of their jobs. The biggest challenge, however, lies with reimbursement sources from payors like CMS and larger insurance companies who want to pay less for modalities. RTs must constantly work to make sure a customer qualifies for reimbursement.

“We’re an easy target,” says Adler. “The industry hasn’t done a good job of protecting itself.”

Advice from the Inside
Thinking of adding an RT to your business? Be sure to analyze the bottom line, advises Adler. The business must be able to support upfront costs in order to benefit from the rewards in the future.

Welker also encourages providers to get a handle on how many customers an RT can efficiently serve. “It’s quite a balancing act,” he says.

But that balancing act comes easily to CARE. “We love what we do,” says Adler. “We’re in really challenging times with the industry right now and all of the changes with the capped rental and oxygen provisions and the PMDs and all of the regulatory changes and competitive bidding on the horizon. But we’ve been in business for going on close to 40 years now, and we’ve survived carrier changes and a lot of other things that have gone down over the last three decades. I’m sure that we will survive these changes that CMS is placing on us also.”

MetroCare Home Medical Equipment

A Day with an RT: Dallas-Fort Worth Respiratory Therapist Discusses Job Responsibilities
To hear MetroCare Home Medical Equipment’s Nada Davisson, RRT, tell it, the heart of respiratory therapy is education.

“We are constantly educating everyone that may be in the path of care for respiratory patients,” says Davisson.

The other responsibilities of her job — intake, warehouse and delivery, sales and billing — do not compare to her primary mission to educate everyone involved with a client, even other respiratory therapists not familiar with home care.
“As a clinician, part of my job in sales is educating referral sources about choices that will enhance quality of life,” says Davisson.

Respiratory Management asked Davisson to walk us through a day in her life. Here’s what she had to say.

Educate and Assess
Getting clients to be compliant with their therapy requires a certain amount of coaching, and that’s where a respiratory therapist proves most valuable.
“Often these patients are anxious,” says Davisson. “We have to be able to soothe them and coach them along the way.”

Clients gain that trust by the respect, resourcefulness and caring that an RT shows. RTs must work hard to establish that trust so that clients look to them for important advice about equipment.

“Many patients today shop on the Internet and find information that may not be suitable for their needs,” says Davisson. “The respiratory therapist has to have a confidence level in directing them. A strong foundation of clinical skills and experience is necessary or the patient will not have trust.”

When an RT enters the client’s home, the goal is to set up the equipment, educate the client and assess the situation. That means assessing the cognitive ability of the patient as well, says Davisson. If a patient cannot understand how to use a piece of equipment, he or she will not be compliant. Likewise, the RT must look for any physical limitation that could hinder use.

For an RT, one day is rarely like another. As a result, the clinician must be flexible because a new order may come in that must be delivered as soon as possible.

“Maintaining flexibility and the ability to redirect to handle the shift is crucial to the well-being of the patient and the company as a whole,” says Davisson. “If a new order comes in, a certain amount of time is dedicated to review the documents to ensure that the order will be executed properly. Once the process is completed, the therapist will work the setup into their schedule.”

Generally, the RT will do the following for the different segments of respiratory:

  • Oxygen — First and foremost, an RT must review oxygen orders to determine the type of delivery device, liter flow, activity level and how long a patient will use oxygen each day. The RT also checks to see if portability is needed and if the patient qualifies for the device through payors. Next comes the education part. RTs talk to the client about how to use oxygen and care for the equipment and also what safety measures must be observed. But the responsibility doesn’t stop there for this labor-intensive modality. The RT also reviews compliance data and assesses if the oxygen is meeting the client’s needs. If a problem arises or another delivery device is necessary, the RT notifies the physician.
  • Sleep Apnea — The RT reviews both the polysomnography and the titration study to determine how the patient has responded to the therapy. The study provides valuable insight such as sleep position, stages of sleep experienced, length of sleep with the CPAP or BiPAP, frequency of waking and SAO2 level. Then the order is reviewed to determine the proper setting, type of machine and type of mask. The RT must then determine if a humidifier and/or supplemental oxygen is needed.
  • Asthma —An RT provides information about the correct use of peak flow meters and aerochambers to maximize the use of MDIs. In addition, Davisson encourages clients to keep diaries to help manage respiratory medications. Providing information, education and resources on this disease process can greatly improve the daily lives of the asthma patient.

With all of these duties, the day can get pretty hectic. Part of time management, says Davisson, is keeping appointments on schedule. “The process of going into patients homes should be done with respect and in a timely manner,” she says. That means observing the proper infection control procedures, ensuring detailed education for the client and caregivers, resolving maintenance and safety issues, discussing the importance of compliance, outlining long- and short-term goals, and often talking about the client’s financial responsibility.

You Are What You Teach
To educate, RTs must educate themselves. That means staying current on CEUs and attending educational workshops, says Davisson. It also means having a good grasp of the current equipment on the market.

“Expertise in choosing the correct equipment comes from having the drive to constantly be up on the latest and greatest technology,” she says. “There are so many products on the market today. We rely on our manufacturer reps for information, and also experience plays a vital role in what really works.”

Coping with Competitive Bidding
MetroCare is located in one of the first 10 MSAs set for competitive bidding, a fact sure to take its toll on the service component of the business.

Still, the company plans to add at least one more RT to its staff as the company expands its sleep program into the private and managed care sectors. Competitive bidding has MetroCare President Susan Kelly worried about the future of the industry as a whole.

“The implementation of this (competitive bidding) process will not reduce the importance of a respiratory provider to have an RT on staff,” she says. “It will only reduce our ability to do so. This process will put at risk the oxygen provider’s ability to provide essential respiratory therapy and other critical patient support services that have been completely overlooked. This translates to a potential disaster for the most frail and needy of our nation’s Medicare population.”

This article originally appeared in the Respiratory Management May/June 2007 issue of HME Business.

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