Respiratory Therapy and COVID-19: Challenges in Skilled Nursing and Home Health

Providing optimal respiratory therapy care amid COVID is crucial for your skilled nursing facility or home health care team. Respiratory therapists are among the many healthcare professionals doing heroic work on the front lines of the COVID-19 pandemic.

As a post-acute care leader, you will want to ensure that your respiratory therapists are trained in evidence-based best practices and that they know how a patient’s care will be classified under the Centers for Medicare and Medicaid Services (CMS) payment model for your care setting.

In other words, they need to know how to provide the most effective respiratory care while considering the coding and billing constraints under the CMS payment models.

A recent Relias webinar explored these topics with Kevin Cahill, MS/RTT-NPS, Medical Specialist at Syracuse VA Medical Center, and Corinne Epton, MA, MHA, CHC, Manager of Regulatory Compliance at Relias.

PDPM and Respiratory Therapy in SNFs

In skilled nursing facilities (SNFs), the Patient Driven Payment Model (PDPM) dictates the reimbursement for patients needing respiratory therapy during short stays. As Epton noted during the webinar, the sicker and more clinically complex the patient, the more money the facility receives to provide that higher level of care.

To maximize reimbursement rates under PDPM, nursing homes now will likely seek to provide care for more complex and higher acuity residents, Epton pointed out. That care can include physical therapy and occupational therapy, but also nursing and nontherapy ancillary (NTA) care such as respiratory therapy, depending on the patient’s needs. The nontherapy ancillary payment is based on the presence of comorbidities and the extent of services needed.

Respiratory conditions and extensive services include ventilator-respirator care, asthma, COPD, chronic lung disease, cystic fibrosis, trach care, cardio therapy, and even pulmonary fibrosis.

SNFs seeking to expand into respiratory therapy care to take advantage of the high-acuity reimbursements under PDPM will need to be sure they have competent respiratory therapists on their team.

PDGM and Respiratory Therapy in Home Health

For home health patients, the Patient-Driven Groupings Model (PDGM) applies to the Medicare reimbursement calculation. Compared with the previous home health payment model, PDGM represents a shift from volume to value. The intent was to shift the focus from volume of services to a more patient-driven model that relies on patient characteristics and other patient information to determine meaningful payment categories.

PDGM places a greater emphasis on diagnosis than the previous model did. In addition, quality of care is emphasized in the newer payment model, Epton noted.

So leaders in each setting, SNFs and home health, need to understand how respiratory therapy fits into those payment models and ensure that they have respiratory therapists qualified to provide that high-acuity care.

Respiratory Therapy and COVID: Crucial Patient Care

CMS officials had several goals when they initiated these new payment models. And then coronavirus came along and shifted the priorities. In the early days of COVID, CMS issued a variety of waivers to healthcare providers, and many of those are still in place.

The importance of respiratory therapists has come to the forefront as clinicians in different settings have joined forces to treat people who test positive for COVID-19 and those who have COVID long-haulers symptoms. Treating COVID-related respiratory conditions has been an urgent need during the pandemic.

In a way, the timing of the PDPM and PDGM rollouts was ideal because they both place heavier emphasis on meeting NTA needs. They provide funds to care for patients or residents who receive Medicare coverage but don’t require PT, OT, or SLP but do require respiratory services.

Clearly, reimbursement has been an unpredictable ride over the past year, Epton noted. And of course the COVID crisis is not over yet. Researchers are still seeking more insight into COVID long haulers and the needs related to post-COVID illnesses.

COVID-Related Challenges for Respiratory Therapists

As COVID continues to affect people giving and receiving care in SNF and home health settings, respiratory therapists need to be prepared to embrace the opportunities and challenges related to COVID, Cahill asserted. Many long-term effects are still unknown.

“COVID has taken everybody by storm,” Cahill said. Many pulmonary patients have reported that COVID has “been really knocking the wind right out of them, literally,” he said, as they have more problems with shortness of breath and tiredness.

Same Precautions, Different Challenges With COVID

In terms of personal protective equipment, a lot hasn’t changed for the respiratory therapy community, Cahill noted. “Over the years, we’ve had SARS, we’ve had the Zika virus.”

With COVID circulating, respiratory therapists are treating patients who are active and patients who were active and are now recovering.

“So right now we are personally wearing a lot of face shields with face masks, gloves, and gowns,” Cahill said, and some colleagues are wearing goggles. The N95 respirator mask is an option, and it has to be fit tested to make sure no leaks occur.

Cahill has a beard, so he could have leaks when wearing an N95. For that reason, he uses a face shield for protection.

Cahill also uses a PAPR mask — PAPR stands for powered air purifying respirator – if he enters a COVID-positive patient’s room. For institutions that cannot afford PAPR masks for all their post-acute care clinicians, he said, the N95 mask is very efficient.

Infection Prevention Is Always Important

Of course, respiratory therapists must disinfect all of their equipment between patient use. “You must clean them between patient use, going in and out of rooms, so you don’t spread it not only to the patients, but to each other,” Cahill said.

“In the big picture, we’ve always had to do this as a respiratory care community because we’ve had to worry about things like tuberculosis in the past,” Cahill pointed out. “Influenza is always an issue during winter seasons.”

“So as far as our community, we just keep at it, we keep diligent on our personal protective equipment, and we keep cleaning and disinfecting. We just keep moving forward into the future,” he said.

Breathing Challenges With COVID

Respiratory therapists are facing the relatively new challenge of evaluating patients with COVID-19. “COVID-19 affects the lung interstitium,” Cahill said. “We have long-term breathing problems, dystonia. And when you have those, they are tied into hypoxemia.”

Many post-acute care patients with COVID have preconditions that make it even more of a challenge to maintain their oxygenation status. “Nasal cannula is the safest and easiest,” way to do that, Cahill said. If the patient breathes only through the mouth, however, the respiratory therapist has to make additional suggestions.

Assess the Whole Patient

Evaluating people with pulse oximetry is another challenge because “not all oximetry readings are accurate,” he said. The respiratory therapist has to be sure we look at the entire patient, he asserted, then “we have to act, treat, respond.”

Whether the patient has COVID or not, the regimen is basically the same, Cahill said. “Look at them, assess them, gather your information, make your decisions.”

A key question, Cahill said, is how well the respiratory therapist understands the therapies. When a therapist is working in the post-acute care area – whether a SNF or in-home care – they need to be aware of their environment and their patient’s needs.

With COVID, respiratory therapists are wearing masks and shields. When dealing with the older population, that can create a barrier to communication and patient education. “COVID has changed a lot,” Cahill said.

One new challenge for respiratory therapy and COVID is that the disease has exacerbated many patients’ underlying conditions. Respiratory therapists have to address these factors so their patients can “go out and live their lives and be productive without sitting home, getting reinfected, and being readmitted to a hospital,” Cahill said.