High Acuity Care Program

1. High Acuity Care Program LifeGas. Living healthcare.

2. Objectives • In this competitive bidding environment it is important to look for new revenue streams. Hear how to target and service the high acuity patient population in your area through the REMEO Ventilator Subcontracting program: • Discuss challenges homecares are faced with • Describe how to market high acuity programs to referral sources • Explain how to manage high acuity patients • Discuss equipment and disposable management options • Key billing tips for this patient population

3. Competitive bidding Challenges in homecare Reimbursement Regulatory / accreditation Cost increases, overtime, DOT etc Displacing technology Getting referrals CAPEX

4. How to Survive with All the HME Changes? • Cut Cost….. Check • Cut spending….. Check • Cut staff……??? • Cut quality of care…..??? • Solutions….. • Take on new patient populations • Offer more to your referral sources • Outsource services You benefit: Accept ventilator patients – and sustain relationships with your case managers. Increase competitiveness by marketing the ability to accept high tech patients. Add a source of income, without adding staff or increasing capital.

5. Keys to success… • Sales and marketing (getting patients) • Billing & collection • Develop or Outsource distribution • Keep fixed costs to a minimum, implement a fixed cost model where possible • Make your company unique • Program focus (specialize) Build core competence Flexible operation Differentiate

6. Home vents do require Trained staff (Respiratory Therapists) Home vents can be done with low amounts of clinical staff Home ventilators require a lot of staff and overtime Home ventilators will increase my liability Home ventilators will jeopardize my Accreditation Status Home ventilators are not Profitable Home ventilators take lots of capital Home Ventilator Patients FACT FICTION

7. Insure adequate Capital Equipment/Supplies are Readily available prior to Start up. Getting started Yes No Accredited for ventilatorequipment? Add ventilators bynotifying accreditingbody Check ventilators, trach supplieson Medicare 855s form Establish Policy Procedure and Training Check ventilators, trach supplieson Medicare 855s form Establish Policy Procedure & Training

8. Marketing LifeGas provides: Monthly home visits by a licensed Respiratory Therapist Respiratory Therapist on call 24/7 Equipment and gases Care and training • Key Points for Referrals: • Standard training time to discharge the patient • Availability to begin training in a timely manner • Willingness to work with hospital staff on training • Demonstrate On- call support • Do what’s best for the patient!

9. Communicating The Program To Referral Sources • The placement and care of the ventilator dependent patient involves a partnership among the physician, hospital, home health agency and equipment supplier. Because of the importance of ongoing patient care in the home setting and necessity of reliable response systems, the referring hospital/physician may at times consult with the home health agency prior to any selection of equipment supplier.It is key to market your program and services to both Hospitals and HHA.

10. Discharge Opportunities • ICU • Crowded units • Infection risk • Very expensive • Solutions • Provide prompt training for timely discharges • Have availability of the latest technology quickly. • Ventilation & Weaning center • Small units (<25 beds) with “home feeling” • Weaning rate of 50-75% in the US • Home • All equipment and supplies • Care giver training • Monitoring for weaning possibility • On call

11. Caring for High Acuity Respiratory Patients You manage: All marketing Intake and insurance verification Maintain continued communication with physician and customer Provide support to customer (business and after hours) Billing and billing related duties • Key Factors • Market Research • Personnel • Equipment needs • Training • Policy and Procedures • Acceptance Criteria • Follow Up

12. Market Research • What patients are we targeting? • How many patients are out there? • How many competitors in the area? • How can I be the best in my area? • What do referral sources want from a vent program? • What equipment combinations will the customer be looking for? (Types/brands, etc) • Will I get any spillover business from taking vent patients?

13. Personnel • Need a minimum of 2 clinicians willing to share 24 hour call • Lead therapist? • Both therapists need knowledge and experience with vent patients • Must be a good teacher and also a good learner • Must be able to make decisions & communicate effectively with caregivers • Telephone skills & support will be key to program success

14. Capital Equipment • Ventilators: • average $10K/plus • Different referral sources may want different types of equipment • Technology changes often (5-7 year cycle) • Patient or insurance provider may decide to change companies, leaving you with unused expensive capital equipment • Other equipment needs: • Portable suction • Specialty secretion clearance devices • Backup batteries • Backup ventilators • Disposable (Trach/Trach care kit/yaunker…etc)

15. New Technology- < 5years old

16. Ventilator Comparison

17. Policy and Procedures • Will be the most detailed and time consuming process of the startup • Responsible party must be well versed in state/federal/accrediting body requirements • Will take weeks/months to prepare • Consider a consultant/guidance from industry associations

18. TRAINING, TRAINING, TRAINING • Internal staff training • Policies & Procedures • Equipment (try to standardize) • Clinical training • On call services • Laws and regulations • Patient/Family training • Must be comprehensive • Must include both homecare staff and hospital staff • Must have competency check off and hands on • Caregivers must know emergency response procedures • Repetition, Repetition, Repetition. Take the time to insure compliance • Must be flexible

19. Acceptance Criteria • What are the characteristics of a “good” vent patient referral? • Is the patient stable? • What is the home environment like? • How is the patient’s family situation? Adequate caregivers? • Relying on home health nursing is not the answer…. • Within scope of practice and state laws • There are patients that are better off in another care environment

20. Patient Follow Up • Establish a policy for the Follow up. Home Visit s should be scheduled to reduce/eliminate unnecessary readmissions. • Example: • Week 1 – A clinical home visit shall be conducted once within 48hrs following Home Set Up. • Week 2 – A clinical home visit shall be conducted 1 time. • Going Forward: Once monthly and as needed. • Report any recommendations to the physician and maintain a strong communication with the family/caregivers.

21. Other Considerations • National laws • State laws • Delivery Tech vs Respiratory Therapist • Patients transferred on unfamiliar equipment • Patient improvement

22. National and State laws • Each state has different laws governing Respiratory Care • FAQ: Is applying NC considered Practicing Respiratory Care? • In some states yes, depending on the state Respiratory Practice act. • FAQ: Is applying CPAP and BIPAP considered Respiratory Care? • Again in some states yes, refer to your states Respiratory Practice act to confirm. • FAQ: Is applying Mechanical ventilation considered Respiratory Care? • Yes, this is considered practicing respiratory care in every state. • FAQ: What if I am unsure about the Respiratory Practice act interpretation? • Contact the Board of Respiratory Care in your state

23. Definitions • Equipment/ delivery tech-Is responsible for the delivery of equipment and instruction to the use of the equipment, safety of equipment, cleaning and disinfecting, and trouble shooting • Clinical Respiratory Care-Pertains to “hands-on” assessment and treatment of the patient in need of respiratory care, including: • Observing and monitoring the patient • Teaching disease management • Clinical assessment • Medication use & administration • Patient/ caregiver education

24. Outsourcing Options • Equipment- Buy VS Rent • Purchasing Equipment • has large expense up front which sometimes takes multiple years to make up • Ventilator have high ongoing maintenance costs (500-2000 for pm’s) • Rental Equipment • Factored in monthly price • Easy to budget • No maintenance costs • Billing Services • Prepare staff “before” taking patients • Consider outsourcing if no support available • Disposables • Develop a standard supply list to build off of

25. Game-Changing Revenue Enhance your offering, without expanding your budget. One vent patient provides the same revenue as seven home oxygen patients. 1:8

26. The bottom line It just makes sense.

27. According to Medicare guidelines, tracheostomy supplies must be provided by the primary Home Health Agency directly or under arrangement. This information can be found in the Home Health Training Manual, 2007, section 4.1.1.2, and section 4.1.12.1. Payments for these supplies are bundled into the home health agency prospective payment system, which means a portion of the prospective payment system rate represents payment for the supplies, including the supplies not listed in the plan of care. The home health agency, may make arrangements with the DME company providing equipment to the patient, or another provider, to provide the supplies needed in conjunction with the plan of care for the patient at a special retail price. If no arrangements are made prior to the patient’s discharge, the Home Health Agency will be responsible for providing any and all supplies that are referred to per the consolidated Home Health Billing System (PPS). The following supplies are the most common to be denied due to Home Health Consolidated Billing (PPS)………………….. A4217---Normal Saline (Box of 100) A6402 ---Trach Drain Sponges (Box of 25) A4623 ---Trach Inner Cannula (Each) A4624---Suction Catheters--- (Each) A4629---Trach Care Kits (Each) A7525---Trach Mask, Adult (Each) A7526---Trach Collars, Adult (Each) A7521---Trach ,Various Sizes & Types (Each) A7520---Trach, Cuffless Fenestrated (Each) Tracheostomy Supplies & Consolidated Home Health Billing (PPS)

28. Billing Reminders for Home Ventilator Patients • If patient is prescribed oxygen, don’t forget to have a qualifying O2 saturation two days prior to discharge when applicable • It takes approximately three days for a respiratory therapist to adequately train the caregivers on the ventilator. • Make sure to verify if patient will be receiving home health services, due to the fact that some trach supplies fall under the consolidated billing (PPS). • Verify if patient has had DME equipment before from another provider.

29. Billing Tips Cont’d • Don’t take a vent patient home on a Friday, due to the weekend. • Make sure to follow all standard insurance verification of benefits for DME. • Have all Dr.’s written orders in the office prior to set up. • Notify the local utilities company that you have a ventilator patient in case of an emergency. • Ventilators use standard orders for billing, there is no designated CMN for them.

30. Thank you foryour attention. LifeGas. Living healthcare.