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Duane M. Johnson, PhD Senior Partner, SCMI

13 th Annual Focus Conference Niche Sleep Services That Can Be Added To Your Sleep Program May 12, 2013. Duane M. Johnson, PhD Senior Partner, SCMI. Why New Revenue Sources Are Needed!. Lower reimbursement pressures More regulations Greater sleep lab competition

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Duane M. Johnson, PhD Senior Partner, SCMI

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  1. 13th Annual Focus ConferenceNiche Sleep Services That Can Be Added To Your Sleep ProgramMay 12, 2013 Duane M. Johnson, PhD Senior Partner, SCMI

  2. Why New Revenue Sources Are Needed! • Lower reimbursement pressures • More regulations • Greater sleep lab competition • Current national economy woes • Protect existing referral and patient relationships • Attract more patients and new referral sources • Increase financial results and future business security

  3. Ten New Revenue Source Opportunities • Oral Appliance Therapy for CPAP failures • Cardiology/Catherization Screenings • Sedation Apnea Management (SAM) Screening and Service • Home Study Primary Care Ventures

  4. Ten New Revenue Source Opportunities 5. Pain Clinic Services 6. Weight Loss Clinics/Bariatrics 7. Diabetes Specialty Sleep Initiatives 8. Business and Industry Safety Programs 9. Insomnia Program 10. Women’s Sleep Services

  5. Dentistry’s Role in the Diagnosis and Treatment of OSA

  6. Dentistry’s Role in the Diagnosis and Treatment of OSA • Obstructive Sleep Apnea (OSA) is a life threatening medical disorder • Dentists are not medically qualified nor legally permitted to diagnose sleep disorders • Diagnosis must be made by a physician

  7. Dentistry’s Role • Screening and referral • Provide and monitor oral appliance therapy as part of treatment team with physician • Monitor and treat potential side effects of oral appliance • Follow-up

  8. OSA Physical Exam Risk Factors • BMI>30 • Neck Circumference >16in • High arched palate • Micro/retrognathia • Mallampati class airway

  9. Oral Appliances • “Oral appliances present a useful alternative to continuous positive airway pressure (CPAP), especially for patients with simple snoring and patients with obstructive sleep apnea therapy who cannot tolerate CPAP therapy.” • Wolfgang Schmidt-Nowara et al. Oral Appliances for the Treatment of Snoring and Obstructive Sleep Apnea: A Review; Sleep, 1995; 18(8):501-510

  10. Practice Parameters • Practice Parameters for the Treatment of Snoring and Obstructive Sleep Apnea with Oral Appliances: An Update for 2005 • An American Academy of Sleep Medicine Report. • SLEEP 2006; 29(2):240-243

  11. American Academy of Sleep Medicine Clinical Guidelines • Oral Appliances are indicated in: • Patients with mild to moderate OSA who prefer them to continuous positive airway pressure (CPAP) therapy, or who do not respond to, are not appropriate candidates for, or who fail treatment attempts with CPAP • SLEEP, Vol 29, No 2, 2006

  12. American Academy of Sleep Medicine Clinical Guidelines • Until there is higher quality evidence to suggest efficacy, CPAP is indicated whenever possible for patients with severe OSA before considering oral appliances. • SLEEP, Vol 29, No 2, 2006

  13. Other Indications for Oral Appliance Therapy • As an adjunct to CPAP • For use during travel • For use when electricity is not readily available (camping, etc.) • In combination with CPAP to help reduce necessary pressure changes or to eliminate head gear • As a predictor of success of ‘bi-max’ advancement surgery

  14. American Academy of Sleep Medicine Clinical Guidelines • Diagnosis • Medical Evaluation to Precede Appliance Therapy • Appliance Fitting • Appliance Selection and Fitting by Qualified Dental Personnel • Follow Up • Medical Assessment PSG for Moderate and Severe OSA • 6 Month/Annual Evaluation by Dentist

  15. Major Legal Concerns • Compliance with local licensing requirements (check with your state) • Issues of professional liability • Due to the nature of oral appliance therapy, certain aspects of treatment fall within the scope of practice of physicians and certain others dwell within the scope of practice of dentists.

  16. CPAP and OA Treatment

  17. Oral Appliance Therapy

  18. How Do They Work? • Oral appliances are utilized in the mouth during sleep to prevent the oropharyngeal tissues and the base of the tongue from collapsing and obstructing the upper airway.

  19. Oral Appliances May Function in 3 Basic Ways • Repositioning the mandible, tongue, soft palate and hyoid bone • Stabilizing the mandible, tongue and hyoid bone • Increasing the baseline genioglossus muscle activity

  20. Functional Classification of Oral Appliances • Tongue Retaining Appliances • Mandibular Repositioning Appliances • Combination Oral Appliances and CPAP

  21. The Silent Sleep • Non custom (less expensive) • Easily fit with VPS (denture reline material) • No boiling • Easy to alter position • May be relined as many times as needed • Excellent trial or temporary appliance • May be used in youth or children • May fit directly in the sleep lab • Dental/TMJ uses as well

  22. Standard Protocol • Referral from phsyician • Initial exam • Records (study models, bite registrations, imaging, other) • Fitting of appliance • Follow up visits for comfort and efficacy • Follow up objective study (pulse ox, ambulatory unit) • Referral back to physician for consideration of follow up PSG with titration of the appliance in the sleep lab • Alteration of the appliance for long term success • Long term follow up with regular maintenance and replacement of the appliance

  23. How a Dentist might do things… • Screen ALL patients for bruxism, snoring and sleep apnea (Epworth, GASP, Bruxism Questionnaire) • Treat the patient with the Silent Sleep For Bruxism • Refer the patient to their family doctor for consideration of a sleep study • Follow up with the patient for creation of a long term treatment plan

  24. Follow Up PSG or HST with Titration • Refer patient back to their physician for consideration of follow up PSG or HST with titration of the appliance in the sleep lab • Need to provide the sleep lab with written protocols for titration • Have the patient return to review results and to determine the next step • Good position • New treatment position? • OA not effective – combination therapy? • Annual follow up • Replace appliance every 2 to 3 years • Oral appliance therapy in LIFETIME therapy for most patients

  25. The Bottom Line • Sleep Apnea is a serious health concern with a high prevalence in our society • Dentists can play an important role in the diagnosis and treatment of sleep disordered breathing (SDB). • Oral appliances are useful in the treatment of SDB and are often better tolerated that CPAP and can be used adjunctive to CPAP or in combination with CPAP. • You Can Do It!!!!

  26. Keys to Success: Cardiology • Make it easy for Cardiologists to refer SDB patients • Screen for SDB before Cardiologists see patients in clinic (who, what and when) • Streamline Process (i.e. EMR/Paper Charts) • Education: Physicians, Extenders, Staff and the Patients • Time Line to start Treatment

  27. Three Landmark Conclusions from the Latest Research: • Up to 50% of cardiologist’s patients suffer from Sleep Disordered Breathing (SDB). • Treatment of SDB has therapeutic value for many types of cardiac pathology. • Sleep Centers have a diagnostic value in the detection of cardiac pathology. Many patients exhibit cardiac abnormalities only during sleep.

  28. Indications for a Sleep Study • Congestive Heart Failure • Refractory Hypertension • Refractory Angina • Left Ventricular Systolic Dysfunction • Ischemic Heart Disease • Arrhythmia • Myocardial Infarction • Stroke IMPORTANT: These diagnoses allow reimbursable sleep studies to be performed.

  29. SDB Co-Morbidities

  30. Samples from Current Literature Lung Biology in Health and Disease The leading medical text book on Sleep & CVD by TD Bradley and JS Floras; Marcel Dekker, Inc, New York, 2000 In the chapter entitled: Sleep Apnea: Implications for Cardiovascular and Cerebrovascular Disease Links the Comorbidities of SDB and: • Drug-Resistant Hypertension = 80% • Hypertension = 45% • Congestive Heart Failure = 50% • Stroke = 60% • Coronary Artery Disease = 30%

  31. Conclusion The detection and treatment of Sleep Disordered Breathing no longer lies entirely in the realm of the pulmonologists. It is a must for cardiologists and their patients.

  32. Sedation Apnea Management

  33. Reasons to Integrate a Sleep Apnea Management Program • Improve patient care • Increasing prevalence for sleep apnea • ASA Practice Guidelines • Reimbursement changes • Pain Management focus • Joint Commission focus • Reduce adverse events • Reduce liability claims

  34. Reduction of costs • Never Events - Hospitals tear up bills for medical mistakes • The Seattle Times January 29, 2008 • Nationally the movement to stop paying for unexpected medical events • RAC audits • Reduce length of stay

  35. Joint Commission • Requirements to manage patients at risk • The process for effective hand-off interactive communication for questioning between the giver and receiver of patient information. Includes updating the patient’s medications • For surgical patients, describe the measures that will be taken to prevent adverse events in surgery • Improve recognition and response to changes in a patient’s condition

  36. Scope of the Program • Reduce risk in patient with sleep apnea who receives sedation, pain control, medication for nausea, anxiety, and depression • Reduce Adverse Events • Requires support of extended clinical and administrative team

  37. How to Start • Obstructive Sleep Apnea Perioperative Screening and Post Operative Care Protocol • Pre-operative screening for OSA – Pre-Admission Services • Pilot a scoring tool • Focused review of Adverse Events using Root cause analyses

  38. How to Start • Define protocol for at risk patients • AHI • Sleep study • Practice Guidelines • Develop discharge instructions/plan • Develop a Quality Management Process • Outcome data

  39. Opportunities • Expansion of service line • Increased referral network • Send letters to PCP and patient • Reduction of risk • Reduction of medical liability • Improved clinical outcomes • Integrate DME communication

  40. Monitoring to Define: • Impaired arousal response • Increased with COPD • Bariatric patients at risk • Orthopedic procedures • May be at risk 6-24 hours after surgery due to residual effects from anesthesia

  41. SAM Summary • Determine the need for a program • Prevalence data • Define the benefits for establishing a program • Demonstrate how to integrate the program into an established care continuum • Revenue sources require careful planning

  42. New Revenue Source Opportunities Home Study Primary Care Ventures

  43. New Revenue Source Opportunities PAIN CLINIC SERVICES

  44. New Revenue Source Opportunities WEIGHT LOSS CLINICS/BARIATRICS

  45. New Revenue Source Opportunities DIABETES SPECIALTY SLEEP INITIATIVES

  46. New Revenue Source Opportunities BUSINESS AND INDUSTRY SAFETY PROGRAMS

  47. New Revenue Source Opportunities INSOMNIA PROGRAM

  48. New Revenue Source Opportunities WOMEN’S SLEEP SERVICE

  49. Opportunities Exist, ACTION Produces RESULTS

  50. QUESTIONS Should you have questions about this presentation please contact the SCMI office at 1-888-556-2203 Email djohnson@sleepcmi.com or info@sleepcmi.com Visit our website at www.sleepcmi.com

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