A Better Way: In Home Care for Texans who are Ventilator Dependent

A Model Program to Reduce the Need for Nursing Home Care

OCTOBER 23, 2014Dorothy HIll, Flora A. Brewer and Friends4816 Blackstone Dr. River Oaks, TX 76114

Proposed: Improved Home Care for Ventilator Dependent Texans Over 500 Texans who live supported by a respiratory ventilator use Texas long term care programs. Experience shows that quality home care is the best option for these Texans. But improvements are needed to meet the needs of this special needs group. Improvements in home care for ventilator dependent Texans is a win-win-win scenario: Better health outcomes; Lower healthcare costs; and Economic development. We’ll show you how.

Who We Represent: 24/7 Ventilator Dependent Consumers Dorothy Hill, is a post polio, 24 hour ventilator-dependent Texan with quadriplegia who lives at 4816 Blackstone Drive, River Oaks, TX  76114. In 1949, at age 14, polio left her totally paralyzed and in an iron lung.  After two years, she came home, finished school and eventually started her own business (in which she employed four other severely disabled persons with quadriplegia). Since 1987, she has been ventilator dependent. Then and now, she has needed breathing aids.  Then and now she is active in trying to resolve unmet needs for the disabled. During  the ‘60's &’70's, while operating her own business, her efforts resulted in the first curb cut in downtown Fort Worth and gaining City Council support for the first handicapped housing in Fort Worth. Since then, she has been fighting another battle to improve care for ventilator dependent patients.  For 62 years she has known the fears of those dependent on machines for their very next breath for survival, along with the fear of “Who will take care of me?”

Conditions Facing 24/7 Ventilator Dependent Consumers in Texas Less than 1% of all the nursing homes in Texas will consider accepting a ventilator dependent patient. Reason: They are either inadequately staffed or unable to meet the unique needs of a 24 hour ventilator dependent patient including cost of care and liability increases. “Among the nation's seven most populous states, Texas ranks last in the number of long-term nursing facilities for adult patients who can't breathe on their own, and near the bottom in how much it will pay for their care.” (2002 Houston Chronicle) Those nursing facilities that accept the additional funding available from Medicaid still struggle to provide quality care in an institutional setting for ventilator dependent patients. For example, in 2007, a Celina nursing home facility that undertook the task of caring for ventilator patients was closed due to a state investigation finding unsanitary conditions, improperly set ventilators, humidifiers and improper use of equipment. (“'Squalid' Conditions Found At Celina Nursing Home” CBS July 2007)

Nursing homes are ill-equipped to care for ventilator dependent patients. According to a nursing home floor supervisor, Dianna Sawyer, nursing homes are so understaffed that it is very difficult to give the care that is needed for these unique clients. Nursing schools teach only the basics about the respiratory system and nurses are told “the RT [Respiratory Therapist] takes care of the rest”. But RRT’s [Registered Respiratory Therapists] are not available in nursing homes for every vent patient admission. Even after being assured by a hospital that a client is stable and would not need any "extra equipment", patients may arrive requiring humidified O2, suctioning every 4hrs and a specially-sized new cannula. Equipment has to be borrowed and may not be available. If the appropriate size cannula is not available, the nursing home must call 911 and send the patient to the nearest ER for a new trachostomy if it becomes dislodged.

A Better Way: Home-based Care for Ventilator Dependent Consumers

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The needs of Texans who are 24 hour Ventilator dependent are uniquely suited to home care. If a patient is sent home with the correct equipment and a trained attendant, emergency department charges and unnecessary hospital stays are avoided. Dorothy uses the Consumer Directed Services option, in which the individual hires and supervises their attendants, maximizing independence. Dorothy has experienced nursing home, in-home, and managed care, through waiver and non-waiver programs.  Based on Dorothy’s experiences in all care delivery modes, home care with trained attendants has been the most effective in meeting the special needs of vent dependent patients, keeping them out of nursing homes and ICU’s, and assuring that attendants are adequately trained and supported. 

Dorothy has managed her post-polio disabilities all of her life and now assists other vent dependent patients.  Today, she trains her own caregivers in a rigorous and structured 3 week program that she has perfected over decades.  She does this while enrolled in a Star Plus non-waiver program, using the Consumer Directed Services option. Dorothy’s dream is that all 24 hour vent patients (as she calls herself) could experience the health and quality of life advantages of living in their own homes with (a) caregivers who are paid a living wage to assure quality and reduce turnover and (b) are paid during a consistent training program provided by a qualified instructor, specialized in respiratory care.  None of our current home care programs assure these elements. 

The cost of nursing home care for ventilator dependent patients was 1.7 times DADS home care cost. (Other program data was not accessible to DADS. No cost data is available for Star Plus patients.) As of 8/29/2013, according to the DADS Quality Reporting Unit, there were 536 ventilator dependent patients in Texas Medicaid funded nursing facilities and home care programs (CBA, MDCP, and the Star Plus waiver program). Annual average charges for CBA ventilator dependent patients were 3.2 times the average cost for all CBA program participants. Annual average cost for nursing home care for ventilator dependent patients was 2.5 times that for all nursing home patients.

What it takes to make Home-based Care Successful for Ventilator Dependent Consumers The second recommendation from the Interim Report to the 83rd Texas Legislature from the Joint Committee on Aging, January 2013 states “in order to ensure that our aging population is receiving the best quality of care possible, Texas must invest in the workforce that cares for them on a daily basis. Strategies that address this need include proper training and payment of direct care workers, geriatric medical training, and continuing education throughout the career of health professionals on the unique needs of the aging population.”

Personal care attendants in the CBA/Consumer Directed Services program are paid approximately $9.77 per hour (given a 2.7% unemployment tax rate) for largely part time work. Wages in the Star Plus non-waiver CDS programs range from $8.68 to $10.80 per hour depending on the managed care company chosen. Attendants in the traditional agency model are paid less. These professionals get no health insurance, must use their own vehicles without reimbursement to get to their clients, and make wages that make them eligible for state and federal welfare benefits (SNAP, Medicaid, housing subsidies, etc.). Their poverty makes it difficult for them to provide consistent care for their clients. A car breakdown can put them out of business. A majority of personal attendants are single women with dependents. According to

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the Center for Public Policy Priorities (www.cppp.org), in Tarrant County, a single parent with one child without employer paid health insurance and no extra money for savings would require a wage of $21 per hour to afford local affordable rents, transportation, food, health and child care.  The wage required goes down to $15 per hour if the employer pays for a health insurance premium.  Only for a single adult, with no children and with employer paid health insurance premiums, does the wage requirement go down to $10.42 per hour with $27 per month allocated to savings for emergencies.  

No specialized training or license is required or provided for personal care attendants, except that required by state law. The client is responsible for all training in the CDS option. The work of caring for a medically intensive person with disabilities requires a great deal of skill, knowledge, and emotional intelligence. A common cold sends a ventilator dependent patient toward respiratory failure. All vent patients are admitted directly to the ICU at $2300 per day.  Proper care limits hospitalization and saves Medicare & Medicaid dollars. Dorothy’s last 3-day ICU hospital stay cost $40,000.00.    The CBA/CDS (or Star-Plus Waiver/CDS) in-home long term care program, structured and scheduled properly, is the most cost effective way for a vent dependent patient to remain in their home. CDS is the only program offering client-trained attendant care, providing for more individualized care.  In the Consumer Directed Services (CDS) option, a home can be transformed into a miniature ICU unit without the infection dangers of institutional care. Institutional care in nursing homes cannot compete with home care in cost or quality of health outcomes. However, none of this is either possible or sustainable without regard for the care givers. Trained attendants for vent dependent clients require the basic skills of the Certified Nurse’s Aide license plus CPR; basic respiratory therapy care; respiratory equipment sterilization and operation; as well as some physical and occupational therapy tasks. 1) Specially trained attendants must be assured of an hourly wage that is sufficient to support

their own health care, child care, and maintenance of their primary vehicle. This is necessary to give patients continuity of care in their attendants. We recommend that CBA and Star Plus programs provide an average wage of $15 per hour, leaving room for experienced employees to receive performance increases with skill and longevity. The median annual wage for Certified Nurse’s Aides in Fort Worth nursing homes is $23,763 (http://www1.salary.com/TX/Fort-Worth/Certified-Nursing-Assistant-Nursing-Home-salary.html) or about $12 per hour including employer paid benefits, making a $15 per hour wage competitive for the attendant in an independent home care environment with a medically intensive patient. Further, moving portions of attendant hours to Protective Supervision at a lower rate is inappropriate for attendants of ventilator dependent consumers. As evidenced by the sample schedule of tasks attached, there is no time when a person of lesser skill can be useful to a ventilator dependent consumer. Doing so jeopardizes their health. Paying skilled caregivers less for a portion of their hours will result in turnover. Attendant reliability and skill are the keys to success.

2) A high quality in home care program for vent dependent patients requires professional support, including the case manager and a Registered Respiratory therapist working as a team to support the client’s evaluation and training of attendants. The case manager or RRT should be available 24/7 for telephone inquiries to provide coaching to the patient and minimize emergency department visits and make a quarterly in-home visit to monitor patient

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condition and adequacy of care. The patient’s Durable Medical Equipment provider must be experienced in supporting in-home patients and be supervised by the RRT or case manager. The CBA program provides for trained supervision, but not all vent dependent patients are placed in CBA. The waiver program, (Primary Home Care) is not adequate to support vent dependent patients. Dorothy was previously on PHC and was only authorized XX hours of attendant care per week and was hospitalized sometimes 3 - 4 times per year. When she convinced her RN case manager to authorize more attendant hours and developed her current attendant training program, she has only been hospitalized 2 times in 5 years, neither of which was respiratory-related.  This saved hundreds of thousands of dollars per year and substantially increased her quality of life.

3) Transportation accessibility was one of the three recommendations of the Texas Joint Committee on Aging to improve the health and welfare of aging and disabled Texans. A simple improvement would be to remove the prohibition against personal care attendants driving their clients to appointments, shopping, and to engage in community activities. Ventilator dependent consumers cannot travel without a caregiver. Allowing the caregiver to drive as well as accompany the consumer makes good economic sense.

4) Without caregivers who are well-trained and dependable, when a ventilator dependent consumer contracts an infection, it currently means an expensive trip to the ICU. These consumers can be well-managed at home, even through recovery from an upper respiratory infection. But to do so takes an increase in direct care service hours. Currently, programs do not allow for increased service hours during recovery from an infection. Caregivers either work without pay, if they can, or the consumer goes to the hospital. Case managers of ventilator dependent consumers must be able to authorized increased hours during an infection to help avoid ICU costs and fairly pay workers.

Nursing Home Care for Vent Patients Can be Improved through the CDS Model The  Ventilator Dependant Consumer needing 24/7 care who has no home or family to turn to, can have quality care by utilizing the CDS trained attendant care program while placed in a long term care facility. Currently, CMS will not allow CDS attendants to be paid when the consumer is in a facility. Unfortunately, facilities don’t have the capacity to maintain trained, available direct service workers just for a vent dependent patient who might be admitted. Further, the facility must quickly provide equipment and staff familiar with the patient’s needs. This usually means that care suffers for CDS consumers in facilities, unless their attendants work without pay. With some specific policy changes, facility care could be improved in the following ways:

Upon contacting a long term care facility regarding admitting a ventilator dependant consumer, whether for respite or long term care, the facility would notify the CDS, RRT Case Manager to coordinate with the facility to set up services for their evaluated care and equipment needs and those needs to be in place prior to admission.

A trained vent care attendant would come for an authorized number of hours per week, same as In-Home Care, to cover the unique personal care needs, equipment checks and availability for special needs outside of the facility normal services.

A Vent Care Program R.R.T should be available for conference calls, emergencies and equipment troubleshooting. The facility nurse would support the do patient’s daily physical condition checks, meds, etc..

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By utilizing the CDS trained attendant care program the long term care facility will be relieved of liability concerns by having assurance that a ventilator dependant patient who faces possible respiratory distress at any given time - has watchful care that ordinarily might be overlooked by the regular staff, with limited time per patient.

Where the Money Comes From for Better Wages and Training: As with many funding gaps in public policy, challenges lie in the fact that the cost savings and cost to implement are in different fiscal pockets. According to the Joint Commission on Aging Interim Report, “any efforts on the state’s part to reduce nursing home to hospital admissions [are] in the best interest of CMS. Not only would it reduce federal Medicare expenses associated with hospitalization, but it would also reduce the risk of poor health outcomes for residents since hospital admissions increase the risk of injury and of hospital acquired infections.” Waiver programs that adequately fund direct caregiver wages and training will be more likely to obtain the desired health and cost of care benefits.

First, Money Follows the Person (MFP) funds can be allocated to fund a pilot program that would move ventilator dependent nursing home residents out into a home care program. The Medicaid waiver process can help states obtain CMS funding for reducing hospitalizations. The Joint Commission cites the Balancing Incentives Program and the Texas Dual Eligibles Integrated Care Demonstration Project as other sources of funding. Cost savings can be more directly attached to cost of care in the new Texas managed care model in which acute and long term care services are becoming co-managed: savings in ambulance, emergency department and intensive care unit hospitalizations can be easily compared with better attendant wages and training expense.

Summary and Recommendation for Research

This proposal recommends a list of steps to improve vent patient care: Preference for home care over institutional care, especially in a consumer directed

model to decrease cost and improve health outcomes; Sufficient attendant hours to assure health maintenance; Living wages for personal care attendants to increase dependability and continuity of

care; Paid training program standards for attendants including respiratory-specific care; Professional teams that include RRT’s with case managers who are easily available

by phone and visit the patient at least quarterly. Flexible increases in direct service hours that allow case managers to authorize

increases in home care service hours to help consumers heal from infections at home and avoid the ICU.

Changes in policy to allow CDS trained respiratory attendants to serve their clients when facility care is necessary thereby decreasing nursing facility liability and improving patient care to eliminate ambulance trips to the hospital, Emergency Department and ICU costs.

To evaluate the effectiveness of care for persons who are ventilator dependent, some of the highest cost patients in Medicare and Medicaid systems, we recommend that evaluation be conducted to accumulate all the costs of care, frequency of hospitalization, morbidity and

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mortality in various types of treatment settings (home vs. institution, waiver vs. non-waiver) associated with variables such as number of hours of attendant care, attendant turnover, hourly wage, amount and type of professional supervision. We must develop best practices for vent patient care that maximizes health and reduces cost. Managed care companies should be required to support this investigation and publish findings widely. Incentives should be base on use of best practices. Texas hospital spent over $16 billion in 2011 on hospital stays for patients who were on invasive ventilation equipment. Twenty-six percent of these patients died. 16% of these expenses went to Medicaid. If even a portion of these hospital stays could be eliminated through improved home care of ventilator dependent patients, the savings in both dollars and lives would be significant. 

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Sample Schedule of Tasks for Personal Respiratory Care Attendant: 7AM - 11:30 AM

KNOCK: Open Door- “HELLO”, it’s me (say name to identify).TURN FRONT PORCH  Light OFF.

7:00 AM Open up blinds as you enter - Each side of front door - Office & Living room (unless still to dark)Monday & Thursday AM   >TRASH DAYS>   To CURB before 7:30 AM to comply with city rules. Wash Hands Thoroughly! TURN ON COFFEE  MAKER.

7:15 AM TO Dorothy’s Room: Turn on lights.  Push IPPB table back; Put remotes in place, Peep Valve in place; Move tissues from bed.  Turn covers back as instructed; PM pillows off bed & place properly. GET ON BEDPAN. Push VENT table back; Scoot “D” Up In Bed.  Put “D” on Bedpan & Cover up “D”. Raise head of bed up all the way.   Place Bed tray on bed, give D a drink of water. Get Mask Sterilization Cup & Put on Bed tray. TURN ON HUMIDIFIER. Change out Vent mask Tube & adapter to day adaptive mouthpiece for intermittent/or continuous breathing. Change Vent from night settings to day settings.

STERILIZE MASK: Put Mask In Cup; take mask to bathroom sink, Fill with cold water, Put in 1 Efferdent tablet, set cup on top of toilet tank to soak; set timer for soaking Time to avoid damage to mask.

PUT WATER/COFFEE ON BED TRAY. TAKE MORNING MEDS. DRINK 1 CUP COFFEE:Same time frame: Fold T.P. for D’s hands, Wet paper towels for “D”s off bedpan use.

7:45 AM Clear Bed tray: Water & Coffee to table.Breathing Treatment Prep: Hang IPPB TUBES in post bracket; Is Med Cup clean? Get out med, Put in place, 

Start Treatment: Uncover IPPB Mouthpiece, Put Med in Cup; Hand tube to DH.(Treatment takes 30 minutes to stretch out air ways with assisted cough needed intermittently to clear airways) Off Bedpan Give T.P. & Wet paper towels to “D”, Move bed tray, Lower head of bed part-way; Take Night Pillow from head, PLACE VENT TUBE; Stool/Pillow in place for assisted cough. WHILE DH cleans private parts with wipes; 

Empty/Sterilize BEDPAN and Prep bathroom: Sterilize sink/Commode thoroughly.  Get out clean wash cloths, Fix Tooth Brush, Anti-Plac & salt rinse.

During Treatment: BEGIN DRESSING:  BRACE ON as instructed; Put bottoms & hose on foot board;Assist W/coughing; all other clothes on clothes rack, P. J. Bottoms off; Hose &Clothing bottoms on;Place lift seat & Back.TREATMENT END: Check D’s capacity numbers; Turn off IPPB Machine. Cover IPPB mouthpiece wash med cup, put in place; hang up tube. Hand D VENT TUBE.

8:30 AM UNPLUG CHARGERS (3) Put cords in place; TURN OFF ELECTRIC STRIP For CHARGERS.PREP LIFT: Roll Lift into place over DH; Plug Orange cord into electric strip, Lower lift; Hook up Lift Seat & Back as instructed; Place D’s Hands on T-Bar ready for Transfer to Chair.

TRANSFER: HOLD D’s NECK!!  Raise lift up all the way; TURN Ankles/legs around/over Bedside; Push & Position over Chair. LOWER LIFT - Push D back in chair securely- remove lift seat & back, fold & put in place. Unplug lift; Roll & hang cord on T-bar & put back in storage place.

8:45 AM IN CHAIR: TURN OFF HUMIDIFIER; Turn bedside vent OFF - Turn on chair vent ON – Check settings. FINISH DRESSING: Shoes on; Tops On.  Assist with hair; Grooming & Oral hygiene.

9:15 AM While DH brushes teeth & washes face up, do following: Go to IPPB & Table: PREP IPPB & Table for next treatment. IPPB tube in place; CK Tissue Boxes, Check Cough lozenges, drops in bedside sack in case needed in the night. Refill HUMIDIFIER BOWL with distilled water. Rinse Mask / Put in Place to dry.

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9:30 AM TO KITCHEN   AND/OR   LAUNDRY ROOMLaundry room: Shower Days: Change/Wash linens. Non shower days Wash clothing as needed & instructed. Washer takes 35 to 40 minutes per load. Dryer takes 60min or more. Toileting

KITCHEN: Prepare & assist with eating Breakfast; Wash/Dry dishes,  Sweep kitchen If needed.

10:00 AM Percussion Treatment: (20 minutes in percussion machine with attendant operating machine. During Treatment Assist W/coughing. 10:25 AM To D’s ROOM: MON, WED, FRI OR SAT: Change out all VENT and IPPB, circuits, filters, and corresponding adapters. Put Reusable tubes and parts in sterilization bowl. TUES, THURS, SAT OR SUN: Shower /Shampoo Days > Important to Rid allergens, airborne germs, etc. from body. Prep all needed items prior to entering shower to conserve time due to vent dependency. (Shower days) Change / wash bed linens.Make up bed each day as instructed / Turning back & fix covers as instructed.   Important to allow for body movement during night when D’s alone. Put needed pillows on bed. Be sure knee, Heart pillows & other assist cough pillows to be in place if hasty access is needed.Check all equipment: Wipe down with Clorox wipes. Check “D” ROOM! Is All Prepared for the mid-day assistant’s tasks? Check Bedside Vent Table:  Mirror is OK; Tissue box is full; Tubes are in order for next treatment.

11:15 AM Check ice trays, fluids intake very important. Ask about LUNCH FOOD> Anything from freezer to thaw, etc.?  Dry/put up dishes; Clean off Counter Top;  Wipe Out Inside Microwave.

11:25 AM Toileting, Be Sure D. Has Liquids on Table Before Leaving & Small Snack If Needed.

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A Proposed Model: In-Home Attendant Training – Ventilator Dependent Patients

Instructor: A Clinical Registered Respiratory Therapist experienced in setting up and overseeing vent patients in a home care setting.

Program Content and Methodology: While the following topics are consistent with basic state required agency training or a certified nurse aide course, agency employees rarely get more than 4 hours training and Consumer Directed employees typically have none as none is required. The following training must be conducted in the home, “hands-on” with the attendant and the particular ventilator dependent client. All topics are intended to cover exactly the needs and issues of the particular patient adapted to their home and their equipment needs, which are never included in basic programs.

Topics:Cleanliness techniques:

Many emergency department visits result from lack of proper cleaning. Germ or a virus ingested can cause Diarrhea, leads to electrolytes issues, nausea/vomiting, danger of aspiration.

Applies to Bed Linens, laundering, washing dishes (washing techniques for sterile dishes), and other kitchen areas needing special cleaning.

Cleaning House (Dust is a respiratory hazard), arranging Furniture to incorporate equipment needs.

Bathing/Personal Hygiene, quick baths/showers (considering client’s vent dependency); grooming & nail care.

Dressing /undressing while working around tracheotomy and vent equipment.

Routine, Hair & Skin Care needs, working around tracheotomy and vent equipment, including training to identify possible Decubitus Stage 1 Ulcers and treatment  

Transfer /Ambulation/Positioning; Exercising/Range of Motion, specific to working around a tracheotomy and/or vent tubing & equipment.

Bowel and Bladder Program, specific to patient

Meal preparation, Eating/Drinking with difficulty swallowing, (usually present with breathing difficulties) including feeding tube techniques, techniques for safe, effective assisted cough. 

Accompany Client along with equipment on trips to obtain health care services, Personal and/or Household Shopping.

Prescribed methods for assisting with self administered medication,

Respiratory Equipment operation and care: Set-up ventilator equipment, enter prescribed settings and controls for client, monitoring same. Change out and sterilize all equipment circuits & filters, clean equipment Charge and keep charged all external and internal batteries. Troubleshoot equipment problems including terminology needed to resolve equipment problems

over phone with DME provider and RRT. Maintain status on ordering of equipment, supplies; and maintenance schedules. Recognize signs and symptoms of infection Perform tracheotomy care and suction Administer in line nebulizer treatments and oxygen at home Quickly activate emergency backup.

Other Patient-Specific Skills training:

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Vital signs Blood sugar monitoring for diabetics Sterile technique for in and out catheterizations Incontinent care Sterilization of all reusable equipment Non-sterile dressing changes

Communication, Reporting and Coordination of Care Monitor and notify nurse of medication changes Recognize and communicate with Nurse/RRT regarding any condition change.

The RRT Manager or Nurse Case Manager would be responsible for performing the following if needed:  Monthly Foley catheter change; Administration of I.V. antibiotics Medi-Port and I.V. care Sterile dressing changes Monthly visit for well check Communicate with MD/NA/RT any sudden condition change  Monthly and PRN tracheotomy inner cannula 

Sample list of classes for the Vent-Dependent Consumer Caregiver Program (note some overlap with personal attendant training requirements and Certified Nurse Aide programs):1. Introduction2. A&P of the Respiratory and Cardiac system3. Vent instruction4. Circuit changes & cleaning5. Infection Control6. Trach Care and Trach changes7. Vital Signs and signs and symptoms of infection.8. Cleanliness of the home9. Preparing meals10. Suctioning, oxygen, and inline neb treatments, IPPB and other equipment11. Diabetes Care12. Catheter changes13. Enteral Feeding. (Food Pump vs. Bolus Feed)14 Good Body Mechanics15. Bathing a patient with dignity16. Trach Collar/Mist17. Passy Muir Valves18. CPT19. Handling family dynamics20. Emergency Preparedness21. Trach Collar and Mist therapy22. End of life issues23. Testing

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Procedure for Initiating Home Care for Vent Dependent Patient

Ventilator patients and their attendants are not adequately prepared by DME provider Respiratory Therapists. Current practice requires only that the equipment be delivered and that someone be shown how to operate the equipment without sufficient time to ensure competency.

Two attendants (to assure back-up) should always be trained to assist the patient Patients must be assessed at the hospital to include reviewing the chart and meeting with the

client and family to review their care and equipment needs. Patients and family members should be informed concerning what to expect about the home care and what training will be required.

A home assessment must be conducted to identify potential problems and safety issues such as adequate electrical capacity for equipment operation; adequate water supply for sanitation; mold; adequate heating and air conditioning

The RRT Case Manager/Instructor should deliver other equipment and supplies a day or two before discharge to give the family or attendant time to get everything arranged.

Following training, caregivers must be tested over the equipment and stay overnight with the patient, preferably at least 2 nights before discharge and perform total care of that patient.

On the day of discharge, the instructor should plan to spend the majority of the day with the family. Once the patient is home and established in care, the instructor may leave briefly, only to return to assist with any additional questions or techniques later in the day.

Before ending the training, the RRT case manager should assess the effect of the move on the patient and determine whether additional oxygen or other changes to treatment are necessary.

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