Compliance • Audits/Analysis • Reimbursement/Regulatory/Rehab • Education/Efficiency
It has been over two decades since the Skilled Nursing Facility (Nursing Home) industry has undergone an overhaul of the reimbursement for Medicare Part A patients. I remember the transition back in 1998 like it was yesterday. The May 12th, 1998 Proposed Rule outlined a RUGS III-34 level Prospective Payment System (PPS) that dramatically shifted the platform of patient care and reimbursement from a cost-based (retroactive) to a per diem based (prospective) system. The industry was upside down.
While there is much to discuss in the realm of patient care, the focus of this blog is respiratory therapy. You see, back in 1998, the advent of PPS included the elimination of respiratory therapy as a “billable service” as opposed to physical, occupational and speech therapy which remained a reimbursable service under PPS through the number of minutes rendered to the Medicare Part A Patient.
Given the reimbursement change, i.e. “the lack thereof for respiratory services”, many skilled nursing facilities eliminated respiratory therapists but continued to provide “respiratory services” within the nursing scope of services.
Per the RAI Manual, Appendix A, Respiratory Therapy Services:
“may be provided by a qualified professional (respiratory therapists, respiratory nurse). Respiratory therapy services are for the assessment, treatment, and monitoring of patients with deficiencies or abnormalities of pulmonary function.
Respiratory therapy services include coughing, deep breathing, nebulizer treatments, assessing breath sounds and mechanical ventilation, etc., which must be provided by a respiratory therapist or trained respiratory nurse. A respiratory nurse must be proficient in the modalities listed above either through formal nursing or specific training and may deliver these modalities as allowed under the state Nurse Practice Act and under applicable state laws.”
Now, let’s fast forward 21 years to 2019.
Given the impending reimbursement changes and transition to PDPM October 1, 2019, it is prudent to evaluate the clinical, financial and operational benefits of reinstituting a formalized respiratory therapy program in your SNF.
The following narrative provides you with the top four reasons why respiratory therapy is needed in a skilled nursing facility:
- Hospital Re-Admissions
Statistics show the primary causes for re-hospitalization are conditions related to breathing. Diagnoses such as Pneumonia, COPD and Respiratory Failure rank in the top 3 etiologies for patients returning to the Hospital, Emergency Room or Skilled Nursing Facility.
Hospital Re-Admissions have negative patient clinical ramifications, hence, CMS, imposes a financial penalty on Skilled Nursing Facilities when the rate of re-admission exceeds the national benchmark (approximately 18% per 2019).
Conventional wisdom tells us that the utilization of respiratory therapy services will help prevent clinical ramifications related to breathing issues. Respiratory Therapy is not just the 4 times per day albuterol nebulizer treatment.
Respiratory Therapy renders other treatments such as: Acapella, Incentive Spirometry (promote deep breathing), Pursed Lip Breathing, HUFF Cough, Respiratory Muscle Trainer Therapy and VEST. Some conditions that indicate said services include Atelectasis, Bronchitis, Bronchiectasis, Cystic Fibrosis, Chronic Obstructive Pulmonary Disease (COPD), Asthma and other conditions producing retained secretions.
- Improved Care / Competencies
Not only will Respiratory therapy help decrease hospital re-admissions, it will complement nursing in providing care to those patients in need of pulmonary expertise. Patients transferring from the acute care setting to the SNF setting require a pulmonary rehabilitation assessment. While in the hospital, the medical team focuses on managing the critical phase of a patient’s illness or disease and services oftentimes do not concentrate on the rehabilitation aspects of pulmonary care. Merely carrying over the hospital physician orders to the SNF does not address the pulmonary rehabilitation needs of the patient.
Respiratory Therapy can assist the SNF with patient assessments, reassessments, accurate documentation, treatment, care planning, non-invasion ventilation, tracheostomy care, pulmonary diagnostic procedures, provision of therapies, staff competency training, quality management support, policies and procedures, admissions assistance and discharge planning.
Adding Respiratory Therapy provides cardio-pulmonary clinical expertise, skills training and aptitudes to offer clinical recommendations beyond nebulizer therapy, including but not limited to:
- PEP Therapy
- Respiratory Muscle Trainer
- Incentive Spirometry
- Breathing Exercises
- Chest Vest Therapy
- Airvo Therapy
- Education on Competency Training and Equipment Usage
- Policy and Procedures Development
- Staff and Clinical Needs Assessment
- Clinical Outcomes
- Increased Reimbursement
On average, the SNF PDPM Medicare Part A rate increase can be upwards of $100 per patient per day (PPD) as seen by the following example.
$ Impact Respiratory Therapy:
Nursing HBC1 vs. Nursing CA1 = Increase $103.64 per day
Case Study #1
Nursing CA1 (No Respiratory Therapy)
Case Study #1
Nursing HBC1 (Respiratory Therapy)
Below is an excerpt from the PDPM Nursing Component Levels
Complementing the skill set of the existing Nursing SNF Staff with Respiratory Therapy helps broaden the range of patients admitted to the SNF.
Managing high acuity Pulmonary patients with low hospital readmission rates positions the SNF to be selected as a preferred provider by Hospitals, ACO’s and Bundled Insurance Providers as well as Medicare Advantage Programs.
In addition, access to Respiratory Therapy supplements Program Development and Clinical Protocol Development, a necessity for the CMS mandated Facility Assessment.
- Tracheostomy Care
- COPD Protocols
- CHF Protocols
- Ventilation Support
- Pulmonary Rehab Program
- Clinical Respiratory Services Program
- Ventilation Unit Management Program
In closing, today’s blog is meant to help you expand your mindset on service delivery in relation the imminent payment changes. The operational, clinical and financial components of running a Skilled Nursing Facility are complex and demanding. My hat goes off to all the leaders and care providers across the country as you provide an exceptional service to our aging population. A service that has historically been undervalued and over scrutinized by the outsiders.
Harmony Healthcare International (HHI) is available to assist with any questions or concerns that you may have. You can contact us by clicking here. Looking to train your staff? Join us in person at one of our our upcoming Competency/Certification Courses. Click here to see the dates and locations.