Hello, my name is Stan. I am a recovering concurrent care-holic. I have been clean for three years. I always knew I needed to come clean and value my RC team as its leader. Coming clean is not easy, for there are many barriers. Yet it can be done. Below are the reasons why concurrent is still alive and further reasons why it must be stopped.
Definition of Concurrent Care:
In respiratory care, concurrent therapy occurs when one therapist administers treatments utilizing small-volume nebulizers to multiple patients simultaneously.
Why Concurrent Care is Still Alive:
Tradition-Concurrent care is not uncommon in acute care hospitals. It is often the "unspoken tradition."
Workload-Sometimes it seems impossible to get all the ordered treatments done. Often, "Q4H treatments until discharge" is the routine order on the majority of the patients. The AARC has CPGs and protocols that have been studied and successfully implemented to control under- and over-utilization.
Inflexible Treatment Windows-How often do we wait to do a treatment because it will throw off the treatment schedule? This batching of treatments puts us at risk when our 911 duties take place.
Unpredictable Work Load changes-RC workloads change very quickly because of the 911 nature of some activities. We average a 13% daily work load change. Averages hide the daily swings of 30-40% changes in workload. Daily work assignments should include a safety factor.
Budgets-Labor budgets, aka FTE, are driven by volume, not value and volume. To provide services that don't have CPT codes, any volume is tolerated. Let's stop.
Budgets-Track revenue (charges), not actual payment. Yet the vast majority of payment is fixed DRG payment. Let's track cost of providing care. For example, what is the cost of providing a HHN?
Benchmarking-Consultants often use methodology that rewards volume, without consideration for value. Methodology must include volume and value so that hospitals are paid as much for value as volume. Inpatient DRG/CPT codes-related procedures and RVU-only procedures are paid the same.
Non-Labor vs. Labor Cost-The non-labor components unit dose medication and nebulizer cost become the primary focus, not the labor component. For example, Albuterol unit dose is less than $1.00 and updraft nebulizers are also less than $1.00. Nobody in their right mind would consider using Xopenex at $2.48 per unit dose and Breath Activate nebulizer at $5.00 each. Yet, typically non-labor budgets 20% of RC total budget and labor is 80% of total budget. This difference of 60% makes it possible to invest $7.48 vs. $2.00 to reduce labor and ultimately reduce DRG cost because frequency of treatments can be reduced by 50%.
All Nebulizers Are the Same-Nebulizer performance should be assessed on ability to meet optimal partial size mass median aerodynamic diameter (MMAD), while achieving a high respirable fraction, and keeping the percent of environmental loss very low.
Why Concurrent Care Must Be Stopped:
Staff Motivation-Quint Studer says staffs are motivated until their leaders do things that reduce their motivation. I will confess I did not realize how I was undervaluing my staff.
Patient Safety-Just because the Beta 1 side effects are infrequent does not mean it is safe. The appropriate administration of respiratory therapy involves assessing and monitoring the patient. Assessment and monitoring include the need for therapy, administration of medications, the type of medication delivery device, patient education, patient tolerance, patient coordination, and outcomes documentation. Concurrent therapy may encourage the elimination of one or more of these essential elements and could result in medical errors.
Compliance with MD Order-When a physician writes an order for HHN, does he know he is getting concurrent care? If he does not, should he be notified?
Medication Delivery Witnessed-How can we assure medication is delivered if we do not witness the entire treatment? Did the patient take nebulizer out of their mouth?
Consistent Medication Administration Practice-Do other clinicians, aka nurses, administer medications to multiple patients at the same time?
Professional Organization-The AARC published a white paper taking a strong stand against concurrent care. How would it sound if a lawyer asked an RCP to read the AARC white paper in court?
Productivity Inflation-Doing multiple patients at the same time skews productivity by inflating it. In my experience, that only made the problem worse. As long as productivity was good, nobody questioned the practice.
Patient Teaching-Time spent on one-on-one care is intended to teach patients about their disease to avoid readmission, etc. The penalty for readmissions is now 3% on Medicare funding; in our case that is approximately $400,000.
Customer Service Perception-One of the four clinical staff questions on the Avatar survey is, "Did the RT spend right amount of time with me?" How does performing multiple treatments simultaneously positively effect this perception?
Accreditation Agency-The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) cites concurrent therapy as a problem; if concurrent therapy is done, there must be a clear indication for it and a policy and procedure that govern its application. JCAHO also says concurrent therapy must be differentiated from treatments given individually.
Billing Errors-Is billing multiple patients for concurrent therapy fraud? Medicare payment is not per treatment, it is a fixed DRG payment. Yet billing for multiple patients as if there care was one-on-one care is not justified.
As I read the great vision the American Association of Respiratory Care painted for us in its AARC: 2015 and Beyond project (www.aarc.org/resources/2015_conferences), I felt that our future is bright and challenging. There are many traditions we should take with us, but concurrent care is not one of them.