CPAP instruction outside the residence.

Compliance with continuous positive airway pressure therapy (CPAP) has been a heavily debated subject for several years and will continue to be as RCP's strive to improve patient compliance. Previously raised issues related to compliance included education provided, humidification systems, choice of interface, ramping, and the use of expiratory pressure relief. Further complicating the compliance issues was a lack of a standard definition of compliance with CPAP. Various medical professionals are defining compliance differently based upon number of hours of usage per night and number of nights used per week.

New models for providing CPAP instruction are emerging as either a one on one instruction in an office setting or multiple patients being educated in a classroom/support group type environment. As with other changes historically occurring in home care, the initial drive for change was economic in nature, but upon a closer look, the benefits extend much further than just financial. It can be a delicate balance for the clinician to provide quality product and service while demonstrating financial responsibility to the organization which employs them.

CPAP, in its short history, (less than twenty years, as a part of home respiratory care), has always been set up and instructed by the practitioner in the patient's residence. With reimbursement continuing to decline and the costs of providing care at the patient's residence continuing to increase, alternate service models came into being. Contributing to increasing costs of the respiratory therapist providing services in a patient residence include increasing fuel costs, health care benefits, wages and non-reimbursable costs of the care provided. Compliance monitoring is a non-reimbursed cost which can greatly effect the cost of services provided. To date, compliance monitoring varies widely between geographical areas. In some areas the home care therapist is required to perform little to no compliance monitoring for the physician or referral sources, while other geographical areas require multiple patient follow ups. Other cost factors include the cost of the therapist while driving to a patient's residence. "Windshield time" as it is referred to by many in the industry, can have a large economic impact on a durable medical equipment provider if the health care professional spends a large portion of their day driving between patients residences. This impacts some organizations more than others depending on such factors as how large the organization's service area, how congested is the traffic within the service area and what effects weather has on driving time within the service area.

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Reimbursement for CPAP varies tremendously between different managed care organizations, Medicare and Medicaid programs. There are managed care programs which reimburse the durable medical equipment provider up to forty percent less than the Medicare allowables for the same service. Many managed care programs interfaces as well, are reimbursed at greatly reduced levels forcing the home care provider to provide the interface at a financial loss.

The trend of the patient coming to the durable medical equipment provider for setup and education has been steadily growing. Many referral sources as well as some home care practitioners initially fought this trend stating home care should be provided in the home. While originally the thought process was to decrease the costs associated with "windshield time", additional benefits have been reaped through programs providing care in an office setting. These benefits include the ability to allow patient's an enhanced choice of interfaces. When providing care in the home, a respiratory therapist can only utilize an inventory of products which can be reasonably carried in their vehicle. When the set up location is changed to the durable medical equipment provider's office the entire inventory of interfaces in all sizes becomes available to the practitioner and the patient to determine which interface best meets the needs of the patient. Organizations are able to allow patient's to try on several different interfaces in order to determine the optimal interface. These display or sample interfaces are cleaned and sterilized making them available to be used multiple times for demonstration purposes. Compliance has been anecdotal and studies are underway to demonstrate that it is equivalent or improved with the patient being setup at the durable medical equipment provider's office.

Factors beyond interface choice are impacting compliance when the therapy is initiated outside the residence. The patient may experience fewer distractions in an office setting and the patient has to put forth an effort to come to the office as opposed to the therapist coming to the patient's residence. These reasons may be part of the reason for improved compliance with CPAP. As compliance is further studied other indicators may emerge as to why the office or support group settings provide the level of compliance they do.

Another alternative to the traditional home setup which is being utilized by some managed care organizations is for the CPAP to be delivered to the patient's home by an independent courier such as UPS[R] or Federal Express[R]. The CPAP comes with an educational video and a toll free number to contact the organization's medical professional with questions or concerns. This method of providing education is new and will need to be studied to determine how compliance is affected by this style of instruction and education.

Homecare is dynamic and with the outlook for reimbursement continuing to decline, one must remember that health care is a business and services cannot be provided a loss for an extended period of time before the provider will be out of business. Providers who are out of business cannot provide needed services to patients. Alternative sites from the traditional home setting for CPAP therapy are an option where quality services can be provided without sacrificing care to the patient. Home care providers as well as all health care professionals will need to be open minded and participate in "thinking outside of the box" in order to optimize care for the patient while effeciently utilizing the reimbursement available for the services.

by James Stegmaier, RRT