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Four types of Home Care Services:

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Home Medical Equipment Services Episodic Home Health Care Hospice Home Health Care Chronic Home Care Services

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Home medical equipment (HME) companies (durable medical equipment (DME) companies)

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provide services by a technician, respiratory therapist, or a qualified nurse

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Episodic home health care

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is ordered for the time period immediately following the patient's hospital stay and is for a finite period of time.

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Hospice care

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is provided for the terminally ill and provides palliative end-of-life care. Usually for up to the last 6 months of the patient's life.

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Chronic home care services (private duty)

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are provided on an hourly basis and involve nurses, health aides, chore providers, and companions.

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Improved medical equipment has resulted in an increase

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in home health care

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medicare encourages

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early hospital discharge

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Modern therapies for the treatment of newborns have resulted in

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more infants and pediatric patients requiring home O2 and home mechanical ventilation.

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Another factor driving the increase in home care is

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the proportion of the population older than 65 years, which is projected to increase to 19.6% of the total population in 2030.

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In the United States, approximately 80% of all persons over the age of 65 have

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at least one chronic condition and 50% have at least two

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Since the early 1990's, increased data support the

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cost-effectiveness of home care for respiratory patients.

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Goals of Home Respiratory Care

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To achieve the optimum level of patient function through goal setting Educate patients and their care givers Administer diagnostic and therapeutic modalities and services Conduct disease management Promote health

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Medicare was established to provide

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a health insurance program for aged persons to compliment the retirement, survivors, and disability insurance benefits.

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part a medicare benefits

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hospital insurance: covers inpatient care, skilled nursing facility care, and hospice care.

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part b

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Supplementary medical insurance. Most people have to pay a premium for Part B coverage. Covers outpatient services, tests, lab services. Also covers home health services including nursing care,

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part c

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low cost alternative to medicare

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part d

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prescription drug coverage

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HME company requirements:

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Retail license/ HME license A bedding supplier license An O2 manufacturer/distributor license Other licenses/permits as required by the state Liability insurance A surety bond of at least $50,000 (to be able to fulfill an obligation to a third party)

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for HMEs you need two types of accreditation

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Equipment Management Services and Clinical Respiratory Services (required if company provides hands on patient assessment, treatment, education, etc)

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accreditation agencies

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Joint Commission, Community Health Accreditation Program (CHAP) and Accreditation Commission for Health Care (ACHC).

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Accreditation usually repeated every

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3 years, but varied depending upon the agency.

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Equipment Management Services

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NOT hands-on patient care services The RT checks the home medical equipment (i.e. the percent oxygen from the concentrator or the ventilator settings and alarms)

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Equipment management services require

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a physician's order for the home medical equipment and settings.

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Clinical Respiratory Services:

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Performing clinical assessments and diagnostic procedures, administering treatments or medications, providing patient education, and monitoring the patient's respiratory status.

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the respiratory therapist is the most competent healthcare professional to provide home respiratory care through

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virtue of education, training, and competency testing,

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Home respiratory care, particularly for ventilator-assisted individuals can be highly complex; therefore

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the risk of negative outcome is great if the services are not performed by a highly skilled professional.

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the most important skill for home respiratory therapists

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The ability to assess many different aspects of the patient

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Must be able to asses patient and care giver's ability to

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understand information that is taught and ability to maintain prescribed medical equipment.

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Must be well-organized and must be aware of

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current insurance coverage for commonly prescribed home medical equipment.

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daily routine of a home care RT is much different from that of a hospital-based therapist.

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Often on call 24-7 Make own schedule A home care therapist often develops long-term relationships with patients and their families.

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What happens on the initial home visit varies depending upon whether

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it is a equipment management services visit or a clinical respiratory services visit.

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If the patient is going home on a ventilator, the respiratory therapist must

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make a visit to the patient's home prior to the patient's discharge to check for any safety issues or inadequacies so that they can be identified and corrected prior to the patient being discharged.

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During the initial visit, the RT should:

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Establish a rapport with the patient and family. Evaluate the home environment. Complete the equipment setup and instruction. Perform any ordered patient assessments and diagnostic or therapeutic procedures. Determine if there are unmet needs and make a plan for addressing those needs. Communicate with other professional caregivers. Complete the required admission paperwork.

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The RT must wear their company photo ID

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at all times, and it must be visible to allay any security concerns.

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The patient should receive a rights and responsibility document;

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explaining their right to refuse services.

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The patient should receive a copy of the company's complaint form;

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which allows the patient to file a complaint.

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If the patient has not already completed an advanced directive, they should be given one to complete

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(so the RT knows how to respond to an emergency in the home).

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The patient should receive the HME company's policy for HIPAA compliance.

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How their information will be stored and who will have access to it.

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Home environment must be evaluated for the specific medical equipment being provided.

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(i.e) home O2: no open flames and a working smoke detector.

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The RT may give the patient a list of community resources, such as

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the American Lung Assoc. (ALA), Better Breathers Clubs, Meals on Wheels, etc.

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Home care RTs carry a bag containing

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their hand wash, stethoscope, blood pressure cuff, pulse oximeter, CO2 monitor, peak flow meter, and other necessary implements.

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Because the RT will be traveling from home to home, it is prudent that the therapist minimize the

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likelihood of disease transmission.

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Bag technique means

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keeping the bag and its contents as clean as possible.

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putting bag down on a clean surface like

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blue chux

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washing hands before

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taking anything out of the bag

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wiping everything down after use before going back into

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the bag

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environmental issues

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safe storage of oxygen, electrical safety or back up electrical or battery power, emergency plan/ alarms communication

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safe storage of oxygen

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Smoking or open flames Functioning smoke detectors Securing oxygen cylinders when driving

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Electrical safety/Backup electrical/ battery power

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Electrical outlets for equipment are properly grounded No overloading of any one outlet Priority restoration list (those on vents)

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Emergency plan/ Alarms and communication

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Power outage; backup generator? Battery/ DC battery for car use Alarms must be loud enough to be heard t/o the house Baby alarms and remote alarms

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local ems and firefighter

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Not all patients can communicate the same way; some are verbal, some are not. Must have a means for the patient to contact 911 on their own.

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landline is helpful for EMS to pinpoint location of

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call and quickly find address

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Good for the EMS to visit the patient at home,

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so they know the set-up, etc. If patient is a DNR, this is important, and the documentation should be kept visible somewhere in case they are called to the house.

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Guided Self-Management:

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when patients/ caregivers have appropriate knowledge/ are adequately trained when they can make adjustments to the treatment plan, what adjustments they can make, and when they need to seek medical attention.

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Oxygen in the home or alternate-site healthcare facility is indicated for the treatment of

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hypoxia and has been proven to significantly improve survival in hypoxic patients with COPD.

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The Nocturnal Oxygen Therapy Trial (NOTT) and Medical Research Council (MRC) both

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demonstrated that continuous use of oxygen improves survival.

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home long-term oxygen therapy reduced healthcare costs by

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reducing hospitalizations!

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The goal for efficient oxygen delivery is

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proper arterial oxygen saturation at all activity levels.

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Increased respiratory rate will

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shorten inspiratory time and may reduce the amount of oxygen a patient receives.

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Oxygen dependent patients should be tested

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on their O2 system at different activity levels reflecting real-life conditions- sleep, rest, and exercise, as well as at altitude.

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A 6-minute walk is recommended for

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exercise

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Overnight oximetry is strongly recommended for intermittent-flow oxygen delivery devices,

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to see whether or not the device is triggering with each breath and maintaining the patient's SpO2.

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Either double the dose oxygen flow for altitude or

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perform a high altitude simulation study.

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Patients on home oxygen therapy need to

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stay active to prevent complications associated with a sedentary lifestyle.

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Patients will need to be provided with an oxygen system that is light enough to transport and

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capable of providing the required O2 to meet their needs with activity.

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Continuous Flow:

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Standard for oxygen delivery in the hospital setting with unlimited oxygen supply. Increased activity; increase the flow

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Intermittent-Flow:

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Senses the patient's inspiratory effort and triggers a dose of O2 at the beginning of the patient's inspiratory cycle. All sensing is done through a nasal cannula.

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Oxygen Concentrator:

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Have been the standard for stationary oxygen delivery in the home for decades. Uses Pressure Swing Absorption (PSA) methodology to separate oxygen from nitrogen, with an FiO2 of 0.93 + 0.03. Have become more reliable, smaller, and use less energy over the years. Today's models can produce up to 5 Lpm and produce less noise and heat (which had been an issue in previous years). Good for home use, but ambulatory patients require portable oxygen for when they leave the home.

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Compressed Gas Systems:

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Small cylinders are still used with stationary oxygen, in conjunction with a concentrator transfilling system.

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Small cylinders come in a variety of sizes and shapes designed to provide

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the lightest system for the patient, along with the greatest operating range.

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Liquid Oxygen Storage Systems:

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The greatest storage capacity for oxygen. The concentrator generates oxygen for the portable, but rather than pressurizing the gas, it is liquefied and transfills to the portable. Used for patients that require higher flow oxygen with ambulation.

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Portable Oxygen Concentrators:

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They manufacture oxygen, they don't store oxygen.

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The clinician needs to know the capabilities of a POC to

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determine the appropriate device to use for the patient.

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Patient needs vary as much as the POCs, so

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there is no right POC for all patients

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important points of information for the clinician to consider when working with the patient to determine therapy options.

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Knowing the capabilities of the POC, the needs of the patient, and the activities the patient will be doing while using the POC

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Intermittent-flow devices operate by

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turning oxygen delivery on during some portion of inhalation and off for the balance of the breathing cycle.

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Oxygen is conserved

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two to four times longer than it would be if it were continuous.

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oxygen conserving devices are divided into

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pulse flow and demand delivery devices

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pulse flow

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responds to the pt.'s inspiratory effort and terminates flow at a predetermined time as it is controlled electronically.

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demand delivery devices

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turns on during inhalation and off during exhalation. They use a dual lumen cannula.

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Transtracheal oxygen

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uses a catheter that is placed during a surgical procedure to bypass the upper airway.

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Oxygen conservation is achieved because

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the patient is usually able to be given the equivalent of CFO therapy with nasal breathing at a lower continuous-flow setting.

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A benefit of TTO therapy is an

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increase in patient compliance with therapy because it is hidden from others to see the catheter.

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Reservoir cannulas

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mustache or pendant cannulas) have approx. 20 ml. of reservoir space that stores oxygen during exhalation.

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On inhalation, the patient receives

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that stored oxygen, essentially adding a bolus volume to the ongoing continuous flow delivery.

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Home oxygen therapy is provided in the range of

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1-6 lpm

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flows up to

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15 lpm

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Patients requiring higher flows use a

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LOX system for efficient operation.

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Oximeters are used to assess a patient's

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SpO2.

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Home care providers check continuous flow units with devices that

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monitor oxygen concentration and flow.

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A liter meter can verify

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flow in the home, or determine if extra tubing has caused a drop in flow.

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Carts have helped patients be more

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mobile with their oxygen systems

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Liter meters are devices that are used to

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spot-check the continuous flow from a low-flow oxygen device.

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Medicare will rent a ventilator for a qualified patient as long as medical necessity exits

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however, Medicare places ventilators in the capped rental category.

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The DME provider receives a fee for the first 13 months, after that,

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ownership of the equipment is transferred to the Medicare beneficiary.

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Based on 2005 numbers, there are approx. 10,000 patients on

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home ventilators receiving invasive ventilation

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___ on non-invasive ventilation with a back-up rate.

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7600

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If a hospitalized patient is prescribed home mechanical ventilation

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a comprehensive team approach to discharge planning is required. min 2 weeks prior to discharge

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Most home care companies require that a minimum of

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2 family or lay caregivers be identified and trained prior to the patient's discharge.

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the care givers Must be able to explain and demonstrate

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proper use, troubleshooting, and routine maintenance of the ventilator and all related equipment (bag and mask, suctioning, etc.)

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Caregiver must know how and when to

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order supplies, maintain good infection control processes, verbalize and demonstrate proper response to emergencies such as power outages, equipment failure or accidental patient decannulation.

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Home care RT should work with hospital staff to complete an instructional check list to make sure

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all family and caregivers are properly trained.

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final indication that the patient and family are ready for discharge is

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A 24 hr. live-in demonstration, where family and caregivers perform all patient's care without any help from RT or hospital staff

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There is a high incidence of depression among

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family caregivers

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The RT may want to ask the family member about his/her quality and amount of sleep to determine whether there are

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nuisance ventilator alarms interrupting their sleep (or is the patient having nocturnal issues).

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The RT should also be knowledgeable about

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ocal respite programs, daycare facilities that accept ventilator patients; camps for ventilator dependent kids, or other agencies that may provide some respite for the family caregiver.

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In a report of 621 ventilator users with neuromuscular conditions; one-third were

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employed, and a few others were active on a daily basis as volunteers or students. They can lead meaningful lives!!

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