When I started my career in management and administration by accepting the job of director of respiratory care at Lutheran Hospital in Cleveland, Ohio, approximately a year and a half ago, I actually had little management or leadership experience to draw from and almost no exposure to home health care and the DME industry.

This is not an unusual situation for those who follow the traditional respiratory therapist career path. I had spent the first portion of my career working as a staff therapist and clinical coordinator at a 1,200-bed teaching facility where a team of case managers, social workers, and discharge planners arranged for DME referrals and the respiratory therapy staff had essentially no involvement in the discharge process.

Consequently, I was not prepared for the number of calls I received shortly after I started at Lutheran from local DME sales representatives asking to meet with me to discuss the opportunity to work with our department. I was surprised by the number of companies seeking referrals and the very competitive nature of the business.

And this was not the only surprise in store for me. After meeting with many companies, I was somewhat disturbed by lack of substance and depth in some of their sales presentations. Most seemed to say the same things: “We’re a good company,” “We’re national,” “We’re local,” “We accept most insurance plans,” etc.

An Eye-Opener
To establish the process for referrals and the companies we would work with, I needed to better understand the DME industry. I read lots of articles and publications, asked numerous questions of trusted colleagues, and sat in on a home health care lecture at the Ohio State Respiratory Care (OSRC) State Meeting.

What I found was that the insurance industry and the bureaucratic thinkers in Congress pay little respect to my profession. Respiratory therapy—a skilled profession whose members diagnose, treat, and educate patients who suffer from breathing ailments—was not even considered a reimbursable home health service.

If there was a need for skilled health care professionals in the home environment to treat patients suffering from respiratory disorders, why wouldn’t the insurance industry reimburse for a respiratory therapist to visit a patient’s home? What kind of message was this sending to the DME companies that had to provide this care? Who benefits from a system where DME companies are encouraged to treat patients using the least amount of resources available, all in an effort to maximize profit margins?

It is surely not the patients, who in many instances are not even seen by a therapist once they get home, and it is definitely not the DME companies. Any commitment they make to employ the services of respiratory therapists cuts into their bottom lines.

When I met with the DME providers and started asking questions, I also realized that there was no standard of care. Each DME company operated independently with no real set of established standard-of-practice guidelines. Some companies employed therapists and some did not. Some were accredited in clinical respiratory and others were not.

One common theme, however, was that they all wanted to provide respiratory care to the patients of Lutheran Hospital.

Setting the Bar
Understanding that patient care and quality outcomes drive the health care industry, I felt I needed to develop an improved referral company selection process. When I started my job, Lutheran Hospital used approximately 12 DME companies, and there really was no advantage to this other than lots of lunches provided to the staff.

Lutheran Hospital is not a grandiose, multicentered teaching facility that generates hundreds of referrals each year. It is a 200-bed inner-city hospital that, like many inner-city health facilities, provides care to a very socially and economically mixed patient population. As a result, we may generate only 50 referrals each year. How much dedication and commitment would a company give us over four referrals per year?

It was very clear that some companies were better suited and more qualified than others. So, why would I sacrifice patient care and give business to a lesser company?

Although I must admit there was no scientific approach to my decision, my first action was to narrow the list of providers down to six. I needed to evaluate the companies, talk with their patients, monitor outcomes, and then make an educated decision based on facts. I needed to hold companies accountable for their performance, create a standard set of selection guidelines, and develop a universal plan of care for the patient that the DME company would be mandated to adhere to.

Involving the Patients
Being new to the job, I was asked to create a patient satisfaction question-and-answer initiative. Knowing that DME companies we work with become an extension and reflection of Lutheran Hospital, I decided to focus my efforts on our discharged patients requiring respiratory interventions by creating a patient satisfaction survey. It contained seven statements detailing the professionalism of the company—such as its accessibility and promptness and the cleanliness of the equipment—which patients could rank on a scale from “strongly disagree with” to “strongly agree with.” Any statement that generated a neutral response or worse triggered a call on my behalf to the DME company to inform it that there were customer satisfaction issues that need to be resolved. Because mistakes do take place, the survey was conducted approximately 4 to 6 weeks postdischarge so, in the unlikely event there were problems, the company was given the opportunity to resolve them.

The survey provided me with valuable information regarding customer service, but very little in regard to clinical performance and outcome monitoring. I needed something better. The DME industry was so loosely regulated that some DME companies were not even accredited by an established third-party agency.

I felt that I had to make a change. Knowing that Lutheran Hospital takes a great deal of pride in delivering quality patient care, I decided it was time to roll out that same philosophy to our discharged patients as well.

Meeting with the Suppliers
After numerous discussions with my supervisor in an attempt to refine and improve upon this process, we decided the best way to do this was to personally interview representatives from each company. To remove subjectivity from the selection process, a weighted interview was conducted with questions carrying a score of 0-5 points. Some of the questions asked included:

• What type of quality assurance monitoring does the company incorporate?

• Will the DME company notify the hospital and the respiratory therapy department in the event a patient is doing poorly?

• Is the DME company aligned or affiliated with a full-service pharmacy to deliver medications to the patient’s home?

• What type of travel program does the DME company offer?

• Is the company credentialed for clinical respiratory therapy?

• Does the company employ any multilingual employees or have multilingual literature?

• What was the company’s last accreditation score and did the accrediting organization have any significant recommendations for the company?

• Had the company or its representatives ever been convicted of billing fraud?

• Was the company a preferred provider for any other health care institution?

• Would the company send a therapist to the patient’s home at 1 day, 10 days, and 20 days postdischarge?

• Most important, did the company employ a respiratory therapist? Companies that did not were immediately removed from consideration.

Narrowing the Provider Field
Mandating this level of nonreimbursed work of a company receiving eight referrals per year would be difficult to expect. We considered using a single preferred provider, but after much thought, decided against it because we believed competition would breed quality. Knowing how competitive the DME industry is in our market, we chose to go with the two companies with the highest scores on the interview, both of which were also willing to commit to our discharge plan of care.

With no home health care standard of practice, we felt it necessary to develop our own. Medicare regulations state that patients readmitted to the hospital within 31 days of discharge with the same diagnosis are a nonreimbursable expense to the hospital. By mandating that the DME respiratory therapist assess our patients three times within the first month of discharge, we believe that it will decrease the number of these costly hospital readmissions.

Can a small 200-bed inner-city hospital make a difference in the lives of home health care and DME patients? That remains to be determined. Studying quantitative readmission data to evaluate the effectiveness of this type of referral program still lies ahead. With two controlled DME providers, we intend to study the outcomes.

Whether this type of program is suitable for every health care institution is still up for debate, but with the anticipation of published results detailing the outcomes of the program, we hope someone takes notice. There needs to be across-the-board standardization in this industry and until that happens, it will be the patients who are the ones to suffer. It is our duty as health care providers to mandate a high level of patient care and monitor the outcomes of our patients outside the hospital. Once DME companies, hospitals, the insurance industry, and the legislators in Washington realize this commitment to patient care by all health care providers, then and only then can positive changes be made.

Douglas Laher, BS, RRT, is director of respiratory care at Lutheran Hospital, a member of the Cleveland Clinic Health System and a world-renowned orthopedic center.