Alternative Care Settings

Objectives - Describe recent trends, terms, and goals related to respiratory care in alternative care settings, and describe methods used to administer oxygen therapy and ventilatory support in alternative care settings.

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Recent Developments and Trends

The Affordable Care Act was implemented in 2010.

It:

• Expands health coverage to many uninsured Americans
• Prohibits exclusion of preexisting conditions
• Promotes coordinated care

Respiratory therapists support the goals of alternative care by helping reduce cost and achieve better outcomes for patients.

Respiratory Care Outside Acute Care

Respiratory care in non-acute and post-acute facilities commonly includes:

• Continuous O2 therapy, which is the most common
• Long-term mechanical ventilation
• Aerosol drug therapy
• Airway care
• Sleep apnea treatment and monitoring
• Pulmonary rehabilitation

Alternative care settings include:

• Home care, which is the most common
• Subacute facilities
• Rehabilitation facilities
• Skilled nursing facilities

A comprehensive level of inpatient care is used for stable patients who:

• Have experienced an acute event from injury or illness
• Have a determined course of treatment
• Require diagnostics or invasive procedures

All age groups can be found at these sites.

Home Care

Most post-acute respiratory care is provided in the home.

Common clinical conditions treated at home include:

• COPD
• Cystic fibrosis
• Chronic neuromuscular diseases
• Chronic restrictive disease
• Carcinoma of the lung

Standards and Regulations

Standards for respiratory care in subacute and home settings are derived from:

• American Association of Respiratory Care clinical practice guidelines
• Federal and state laws
• Private-sector accreditation standards

Medicare plays a major role in setting standards for care outside the hospital. Institutions undergo certification surveys to determine compliance with standards, and each state also has regulations for quality assurance.

The Joint Commission is the primary organization responsible for setting patient care standards in the subacute care setting. Approximately 90% of health care organizations voluntarily subscribe to The Joint Commission accreditation.

Acute Care vs. Post-Acute Care

Respiratory therapists working in alternative care settings often:

• Have less equipment and fewer resources
• Work more independently
• Complete more paperwork
• Are often on-call
• Are part of a team approach

Team members may include:

• Provider
• Nurse
• Respiratory therapist
• Durable medical equipment supplier

Discharge Planning

A multidisciplinary team helps with discharge and supports the best patient results.

The appropriate discharge site is determined by the needs of the patient. For discharge to home, caregivers must be trained and prepared. A reliable durable medical equipment supplier may need to be involved.

Oxygen Therapy in Alternative Settings

An oxygen therapy prescription must include:

The most common oxygen delivery system for long-term care is the nasal cannula.

Oxygen-Conserving Delivery Methods

Transtracheal O2 therapy is used in select patients. It conserves oxygen use and has cosmetic advantages.

Demand-flow O2 systems are also known as pulsed-dose systems. They are oxygen-conserving devices.

Oxygen Supply Methods

Ventilator Support in Alternative Settings

Ventilator choice depends on the needs of the patient.

Noninvasive ventilator support is increasing in popularity because it is easier to run, patients are cooperative, and FiO2 is 40% or lower.

A backup ventilator is required for patients who cannot maintain spontaneous ventilation for more than 4 hours.

Home ventilators should be:

• Dependable
• Easy to operate
• Mobile if the patient is mobile
• Electrically powered when dependability is needed

Most patients, especially those with COPD, prefer pressure-limited ventilation over volume-cycled ventilation. The biggest challenge with noninvasive positive-pressure ventilation is getting a good, comfortable, leak-free interface.

Negative-pressure ventilators are rarely used for ventilatory support in post-acute care settings. The iron lung has been replaced with the chest cuirass and wrap or pneumosuit.

Evaluation and Follow-Up

Vital signs, lung sounds, and sputum production should be monitored daily.

ABGs and lung compliance are monitored only on an as-needed basis.

Routine follow-up visits by a respiratory therapist help ensure successful patient management in the home.

Other Modes of Post-Acute Respiratory Care

Bland Aerosol Therapy

Bland aerosol therapy is delivered by jet or ultrasonic nebulizers. It may be intermittent or continuous.

It may be useful for a patient with thick secretions as an adjunct to airway clearance procedures.

Infection is the primary risk.

Aerosol Drug Administration

Bronchodilators and anti-inflammatory medications may be delivered by:

• Metered-dose inhalers
• Dry powder inhalers
• Small volume nebulizers

Reimbursable expenses related to aerosol drug therapy in the home are limited.

Airway Care and Clearance

Patients with tracheostomies require daily care. Tube changes should be done only by a nurse, respiratory therapist, or physician.

Suctioning is provided using a portable electrically powered suction pump.

Patients may be taught to independently use coughing, forced exhalation, active cycle of breathing, and autogenic drainage methods. Caregivers may apply chest physical therapy manually or with mechanical devices when retained secretions become problematic.

Nasal CPAP

Nasal CPAP is an accepted form of therapy to treat obstructive sleep apnea.

For Medicare reimbursement, the diagnosis must be confirmed by a polysomnogram.

Patient Assessment and Documentation

In institutions providing subacute or long-term care, assessment and documentation include:

• Screening
• Treatment planning
• Ongoing assessment
• Discharge

When determining the frequency of home visits, consider:

• Patient condition and therapeutic needs
• Level of family or caregiver support
• Complexity of home care equipment
• Overall home environment
• Ability of the patient to provide self-care

Respiratory therapist home visits include:

• Patient assessment
• Patient compliance with the treatment plan
• Equipment assessment
• Identification of patient problems
• Statement and documentation related to patient goals and the treatment plan

Palliative Care

Maximizing comfort for a terminally ill patient is a goal of home care.

Palliative care involves controlling symptoms such as pain and dyspnea in the terminally ill patient while maximizing psychological and spiritual well-being.

Respiratory therapists may play a key role when lung disease is present in the terminally ill patient.

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High-Yield Review

• The most common post-acute respiratory care setting is home care.
• Continuous O2 therapy is the most common respiratory care service in non-acute and post-acute care.
• Oxygen prescriptions must include diagnosis, flow rate and/or concentration, frequency, duration, and laboratory evidence.
• The nasal cannula is the most common long-term oxygen delivery system.
• A backup ventilator is required when a patient cannot maintain spontaneous ventilation for more than 4 hours.
• Daily follow-up focuses on vital signs, lung sounds, and sputum production.
• Nasal CPAP treats obstructive sleep apnea, and Medicare reimbursement requires polysomnogram confirmation.