Respiratory standards are necessary to assure quality in NCB

Wednesday, August 31, 2005

Standards make an enormous contribution to most aspects of our lives although very often that contribution is invisible to the naked eye. It is the absence of standards that often identifies and magnifies their need and importance.
The home medical equipment industry has changed substantially over the last 20 years, and it is clear today that all HME is not equal. In an industry that lumps an elevated toilet seat in the same category with mechanical ventilators, standards are critical. Technology is advancing at a rapid pace, while concurrently the economic pressures in the acute health care environment are sending more medically fragile and clinically complex patients home. This growing patient population frequently have greater technical and clinical home care needs and less available resources. HME providers are in the business of providing complex health care services; and HME providers are essential in the continuum of care.
An HME provider delivers complex clinical equipment and services in one of the most important yet least regulated and controlled health care settings -- the patient's home. Effective and quality home care can substantially delay or eliminate the need for treatment in a hospital or long-term care facility; provide effective disease management; assist in relieving patient and caregiver stress and encourage a high degree of participation by caregivers and the person receiving care. As a professional health care team member, HMEs have the responsibility to ensure that the clinical care and services provided are consistent in quality to meet the basic needs of all home care patients. Quality is truly scalable. No matter what the financial or physical size of the organization, clinical quality standards level the playing field for both the providers and most importantly -- the patients.
Unfortunately, in HME, the definition of "quality care" can vary widely and is often driven by local practice and in some cases -- competition. There are essentially no nationally recognized or mandated HME clinical standards of care to assure consistency of the professional services delivered. Hospitals and other health care facilities, along with the doctors, nurses and other health care professionals who provide the services are guided by recognized federal and state laws, as well as established standards of care. However, clinical services provided by HMEs are not consistently provided by licensed clinical professionals but quite often by a variety technicians and support workers who may have little or no formal training in health or home care. Thus clinical standards in home care will provide us with needed assurances that the care and services provided to patients in their homes are truly patient-centric.
Competitive Bidding: Quality Standards and Equal footing
Elevating the levels of quality, safety, reliability, efficiency and interchangeability through the establishment of clinical standards will, at the strategic level, provide HMEs an opportunity to drive away some of the negative perceptions that have longed plagued the HME industry. The perception of the person operating an oxygen company out of a garage, providing 15-year old concentrators and heavy steel E-cylinders for portability still sits in the mind of many physicians and unfortunately, many legislators.
The image of the appropriately credentialed and licensed clinical professional or properly trained physician extender working with a medically fragile patient and family in their home is the image that needs to be projected, since it is the daily reality for many HME professionals. Clinical quality standards will guarantee that high technology home care (HTHC) is delivered appropriately and consistently among providers. The standards give surety that the clinical equipment and services are driven by physicians and managed by credentialed and licensed health care professionals. Although non-licensed, trained technicians continue to play a major role in the provision of HME, the duties and responsibilities of these personnel will be directed and managed by licensed professionals [respiratory therapists or nurses] working in conjunction with the physician's order and a patient specific plan of care. As noted earlier, HME is a broad category representing a multitude of products. HTHC is the kind of home care most likely to include the specialists [respiratory therapists] involved with cardiopulmonary and related conditions that require prolonged use of long-term mechanical ventilation, home oxygen, home management of heart failure, pulmonary disorders and sleep disorders.
Some 82.6% of the 1997 count of 562,916 total health care establishments was considered small businesses under the Small Business Administration's definition. Although larger organizations will bear proportional costs associated with implementing standards, some smaller organizations may perceive that this leaves a very large burden on them at a time when the economy and reimbursement rates continue to reduce revenue. The reality is that quality standards are truly one of the really scalable processes. Talks of mandated quality standards can often be initially received as costly, a burden to operation, geared towards a specific size company, etc. However as Tom Scully, former administrator for CMS stated in June of this year during his presentation at the AAHomecare Legislative Conference: "You need to make competitive bidding work for everyone without blowing it up".
The mantra for the health care industry -- quality, access and reduced cost, continues with renewed emphasis as health care costs are rising with double-digit growth. Clinical standards in home care will require us to provide patient-centered clinical services without compromise to afford patients access to quality cost efficient care. The following are a few of the top initiatives for health care and all have a common critical success factor:
- Evidence-based medicine;
- Quality monitoring and improvement -- OUTCOMES!
- Timely population-based health information;
- Bio-terrorism and disease surveillance;
- Reduced medical errors;
- Reduced administrative and delivery costs.
The push for clinical standards has increased in the continuum of care due to these initiatives and many in HME feel clinical standardization in home care is long overdue. If, however, the standards efforts are pursued independently [not as an industry] and do not take into account the many challenges we've experienced in years past -- we may be destined to fail (commoditization) and add more costs, burdens to the healthcare delivery system and create access issues for patients in the least costly environment for care -- their homes. Given the enormous benefits at risk if we do not move forward, there is little choice, but to continue the drive toward standardization.
Our experiences with standards developed by independent accrediting organizations such as JCAHO, CHAPS and ACHC, should inform the process. However, they should not preclude the need to develop fair, yet explicit clinical standards that will be used to guide any competitive bidding process that involves high tech healthcare. Although there is no one right answer, there appear to be a few critical starting points: (1) anticipate the complexity of every institution's environment, (2) broaden industry representation of small and large providers to develop patient centered clinical standards and (3) recommend to the PAOC and CMS minimum requirements for organizations who participate in the competitive bidding process. Regardless of the size of the HME, quality clinical standards are paramount to ensure consistency with clinical services for patients in their home.
Clinical quality standards are a critical foundation for addressing our nation's greatest health care concerns, including medical errors, inconsistent practices, poor services --to name a few. It is time for us as profession to embrace clinical standards for home care and lay the foundation for the future of the HME that best serves the providers and most importantly, our patients.


Vernon Pertelle, MBA, RRT is Corporate Director of Respiratory & HME Services for Apria Healthcare and co-chair of the standards subcommittee for the HME/RT Council of AAHomecare
Joseph Lewarski, BS, RRT is Vice President of Clinical and Government Affairs for Inogen and co-chair of the standards subcommittee and Vice Chair for the HME/RT Council of AAHomecare