When I went to school for respiratory therapy, I think I spent a whole quarter on Intermittent Positive Pressure Breathing (IPPB) – physiological effects of positive pressure, inline aerosolized medication delivery techniques, appropriate machine settings and coaching techniques. We even had to be able to take the Bird apart and put it back together – I mean the inner components – all the pneumatics. Why? Because just about everybody who was admitted got an order for IPPB. Why? Because it had few if any adverse side effects, deep breathing is after all therapeutic, and most importantly, we were paid for everything we did. Respiratory Therapy was a revenue center.
In the 90’s things changed. Respiratory Care became a cost center. The payment models had shifted to per diems, capitation and carve outs. Our mission was to decrease length of stay. Cost centers were scrutinized. But this was a fabulous era for us! Enter, respiratory protocols.
With respiratory protocols, we were allowed to think. We were allowed to access our specialized knowledge of cardiopulmonary physiology and apply our skills in assessment, diagnostics and therapeutics. It worked like this. Physicians would order a protocol and enter any specific outcome parameters or communication points he or she preferred. So for example, with a ventilator protocol the physician may include the preferred patient blood gas range, the specific spontaneous breathing parameters for extubation and/or points of communication escalation (or we default to standard evidence-based values). Bronchial hygiene protocols would allow the practitioner to get more or less aggressive depending upon the patient response to therapy. The point was, respiratory care was at the bedside 24/7, able to evaluate and modify care delivery based on the patient needs, while physicians typically were on site, making care changes just once a day in rounds. We managed the patient essentially between the visits and everyone benefited.
Today’s push toward Population Health and value based care feels just like that. Patients need attention between physician visits, between hospital visits, between ED visits, between home health visits. They need us to be more or less involved to facilitate an outcome – an outcome like not needing to visit hospitals and ED’s – at least not for deteriorating and debilitating conditions – an outcome like overcoming barriers to achieve life’s goals – their goals, not our goals imposed on them. They are the ones who will be setting the outcome goals and we (the community that surrounds them) will apply our collective knowledge and skills to help them achieve those goals together.
And just like when we instituted respiratory protocols, population health management requires some new tools, new operating parameters and trust. And just like the 90’s, though the impetus was financial, and the change was painful, the results benefited all parties involved – patient, physician, hospital, and the respiratory practitioners who were better able to apply their expertise and feel satisfied in their work. We are stepping into another fabulous era with the potential for amazing wide spread results – but buckle up. It’s going to be bumpy.