Rehab can be good for pulmonary care program
Some diagnoses fit within 75% Medicare rule
Rehabilitation facilities can provide pulmonary patients with outpatient and/or inpatient care that can help patients improve their quality of life and result in fewer hospitalizations and emergency department visits.
Such programs also can succeed financially and perhaps will be seen as a more feasible enterprise under Medicare’s prospective payment system. Currently, some pulmonary rehab patients who have multiple diagnoses could qualify and be included in the top 10 Medicare categories, which must account for 75% of all rehab services.
Some chronic obstructive pulmonary disease patients, for instance, may have had a stroke or a neurological disorder that is within the top 10 categories. They would need to be treated in a rehab facility for those problems, and pulmonary rehab would be an additional service.
"It’s just very important that rehab staff know how to treat pulmonary-compromised patients differently from regular patients," says Bill Goodwin, RRT, pulmonary rehab coordinator and respiratory therapist at Grossmont Hospital, a La Mesa, CA, facility that serves the San Diego area. The hospital recently opened a pulmonary rehab program. The rehab facility’s patients meet rehab criteria as set by CARFThe Rehabilitation Accreditation Commission in Tucson, AZ, and they have a strong need for pulmonary care, Goodwin says. "The inpatient care still has to meet acute rehab criteria and have functional gains in physical therapy and occupational therapy, and we just add pulmonary to that," he says.
Four steps to success
Here’s how Grossmont’s pulmonary program was established:
o Set up a multidisciplinary pulmonary team. Grossmont’s pulmonary rehab team consists of physical therapy, occupational therapy, social services, speech therapy, nutrition, a rehab physician, respiratory therapy, and a pulmonary physician. Pulmonary inpatients are evaluated by the team, which implements a physical training program that is pulmonary-focused.
"The team evaluates the patient, determining specifically for each patient how to improve the patient’s activities of daily living [ADLs] and endurance," Goodwin says.
Typically, pulmonary patients are referred from the acute care hospital, either from the intensive care unit or a medical floor. Since physicians can refer these patients to the rehab unit once they are stable, this reduces the length of stay in the acute hospital and is expected to improve outcomes, he adds. Having a rehab unit within an acute care hospital provides a big advantage in setting up a pulmonary program because if a patient has a major problem, the hospital has an emergency department immediately available, he says.
o Design a pulmonary care program. The inpatient program is very similar to a regular acute care hospital stay, except it’s focused around rehab and oriented toward pulmonary disease, Goodwin says. So far there has been an average of five or six pulmonary inpatients. "We try to increase patients’ endurance to educate them on their breathing disorder and the best way they can manage it," he says. "The occupational therapist is very instrumental in providing relaxation techniques and energy conservation techniques."
Therapists also educate patients on how to use their medications, the signs of infection, and how to become more comfortable with and better manage their disease.
Pulmonary patients often have multiple diagnoses, such as steroid myopathy caused by chronic steroid use and osteoporosis resulting from steroid use. The only way to combat those types of problems is through exercise. "But the problem is you have to have a respiratory therapist or physical therapist do a constant evaluation of patients to determine how they can increase their endurance," Goodwin says. That’s one of the reasons the pulmonary rehab program is easy to sell to payers, he says. "The physical therapist knows how to ambulate them without breaking their hips and legs," he adds. Already, the program has improved the distance that pulmonary patients can ambulate by more than 50%, and it has decreased the number of rests they need by 50%, Goodwin says. It also has decreased the incidence of dyspnea by 40% and decreased patients’ oxygen requirement by 33%.
When patients are referred to the hospital, a pulmonary case manager tracks their progress from the emergency department to the acute care hospital stay to inpatient and outpatient pulmonary rehab.
o Create outpatient component. The outpatient program, serving eight to 10 patients per week, provides services for four hours, three days a week, for four weeks. The first week focuses on education from the respiratory therapist and physical therapist on breathing techniques and problems. Patients learn how to determine their inspiratory/expiratory ratio, as well as how to increase their endurance and exercise safely. "We reinforce breathing techniques while they are being exercised," says Goodwin.
In weeks two through four, patients receive information on their cough technique, what their normal peak flow is, and how to use inhalers effectively. "Then we increase their exercise time, as tolerated, from three to five minutes a session," he says. "It’s not unusual for a patient to be able to do six minutes initially and 30 minutes upon graduation."
The outpatient program also has a pre- and post-completion educational test and a six-minute walk evaluation, which is a standard way of judging their level of exercise. "We do an outcomes report on how we have improved their ADLs," Goodwin says.
o Add services to meet long-term goals. Grossmont’s pulmonary program provides patients with in-home training. Therapists evaluate the patient’s home to see if there are a lot of stairs, in which case the patient will need stair-climbing training. They also find out if the patient will be driving, walking with a walker or cane, using a bathroom that has or does not have adaptive equipment, and receiving any help in dressing or bathing. "Our long-term goals are to increase the general health of pulmonary-compromised patients in this market and to provide them with resources as an inpatient, outpatient, and even free resources like our Better Breathers Club and maintenance program," Goodwin says.
He and the rehab facility’s medical director, Kaveh Bagheri, MD, speak at local Better Breathers Club meetings in an effort to better educate the community about pulmonary disease.
Eventually, the Grossmont pulmonary program may include ventilator patients, who require intensive therapy and still will need to meet acute rehab criteria, Goodwin adds. "They still would have to make functional gains, and we’d try to keep the length of stay as short as possible."
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