If you are preparing for accreditation, you need to understand the differences between general equipment maintenance and clinical respiratory care and treatment.
ME providers pursuing accreditation must understand the difference between general equipment maintenance and clinical respiratory care/treatment as defined by accrediting agencies. Understanding a clinical respiratory care protocol to objectively evaluate outcomes and qualify the patient for clinical care is a concern for companies preparing for accreditation.
The definitions are spelled out by the accrediting bodies and are set by each state’s respiratory care practitioner act or licensing agency. What constitutes a clinical respiratory care assessment? The difference between a plan of service and a plan of care must be clearly defined. The plan then must be implemented appropriately to meet the standards of the accrediting bodies.
Providing instruction in equipment use and assessing equipment operations are considered equipment maintenance procedures. Clinical services, however, pertain strictly to “hands-on” assessment and treatment of the patient in need of respiratory care. This includes instruction in medication, medication administration, clinical assessment, evaluation of breath sounds, oximetry, and patient/caregiver education relating to respiratory care. This does not preclude HME companies from using nonclinical delivery staff to provide delivery, setup, instruction, or maintenance of HME. Examples include oxygen concentrators, liquid and gaseous oxygen, nebulizers, CPAP (in some states), and related equipment.
Clinical respiratory care services are usually a component of HME services, but may be a stand-alone service. The service provides clinical assessment of the patient, offering treatment with ongoing monitoring of the patient’s response to the respiratory care practitioner’s intervention and education. Access the accrediting organization’s Web sites and review their official clinical respiratory care definitions.
What is the difference between a plan of service and a plan of care/treatment? (Note: Some accrediting agencies refer to a plan of care as a plan of treatment.) Both plans require an evaluation/assessment of the patient. The initial assessment of the patient will determine the problems, needs, and goals. This assessment will determine the appropriateness of services in the home, safety measures, and patient requirements. The evaluation will also include a social, environmental, and functional component for a plan of service. A plan of care also includes assessment of the patient’s economic, physical health, and mental status.
It is preferable that your organization develop a written assessment protocol, which defines specific assessment techniques and detailed guidelines for evaluating each component. A plan of care must be ordered and approved by the physician before implementation of care or services.
A plan of service should address:
1) Potential problems: Is the patient familiar with the equipment? 2) The need: Does the patient know how to use the equipment safely? 3) The intervention: Teach patients about the equipment so they can comply with the physician’s order. 4) The outcome/goal: Be sure the patient uses the equipment as prescribed and knows how to get in touch with the HME provider. 5) Treatments: What is the modality administered? What is the date, time, and service? 6) The prescribed medication: Ensure proper drug documentation. 7) The monitoring: Take note of clinical procedure findings, physical symptoms, vital signs, auscultation, oximetry results, and document signatures.
The company’s respiratory care practitioner cannot appropriately prepare a plan for care unless a patient assessment is initially conducted. This assessment can range from a comprehensive respiratory evaluation to a one-time pulse oximetry test that will determine the ongoing needs of the patient. A one-time simple assessment to complete a spot-check oximetry test may consist of an abbreviated plan of care including the order and the SAT report indicating that no further action is needed.
The reporting form in the patient’s record should indicate the following: 1) problem description; 2) treatment needed; 3) intervention requirements; and 4) expected patient/outcome/goal of the one-time assessment.
When establishing the patient’s goals, remember to include the patient’s requests. Once the initial assessment is conducted, establish a plan of service or a plan of care. The continuation of assessments is based on the activities and frequency determined by the plan.
Patients/caregivers have the right to be, and should be, involved in the plan of service/plan of care, and participating in any changes to the plan. This should be stated in the “Patient’s Rights and Responsibilities.” The patient/caregiver must agree to the plan prior to the initiation of service or care. The patient’s medical record must reflect the service/care that was provided in accordance to the plan of service/care and show the outcomes that were the results of established goals.
The plan of service or plan of care should dictate when the plan is reviewed and when the patient goals may be changed based on reassessment data.
Your Eyes and Ears Train driver technicians to be the respiratory care practitioner’s eyes and ears during equipment maintenance visits. Educating driver technicians about the early signs of a declining pulmonary patient is important.
Consider completing a clinical assessment on pulmonary patients entering your care to determine their placement in your services. Should they start out as equipment maintenance or be on clinical services? A review of your program of clinical respiratory care with the patient’s physician is necessary and requires signature agreement.
Remember that your clinical respiratory care program should be a revolving process of admitting and discharging as soon as you have completed your plan of care and the patient is stable. There are no industry standards for the percentage of clinical patients versus equipment maintenance patients. The percentage of clinical patients may depend on your patient mix—a company with pediatric patients may have a larger percentage of clinical patients and a company with ventilator patients would have a larger percentage of clinical patients. A company that has only oxygen concentrator patients may have a low percentage of clinical patients. Last, each clinical patient upon discharge must have a discharge summary in the client record and evidence that it was sent to the attending physician.
The following clinical protocols may be considered as a guide while you are building your own clinical respiratory care program. These protocols will be useful in determining different situations or conditions in which a patient would be transferred from equipment maintenance to clinical management.
Wayne M. Link is a specialist in HME/DME company accreditation, consulting, and preparation. He is the founder and president of Link Consulting Group Inc, Columbus, NC, and can be reached via e-mail: wml990@alltel.net
ME providers pursuing accreditation must understand the difference between general equipment maintenance and clinical respiratory care/treatment as defined by accrediting agencies. Understanding a clinical respiratory care protocol to objectively evaluate outcomes and qualify the patient for clinical care is a concern for companies preparing for accreditation. 
Remember that your clinical respiratory care program should be a revolving process of admitting and discharging as soon as you have completed your plan of care and the patient is stable. There are no industry standards for the percentage of clinical patients versus equipment maintenance patients. The percentage of clinical patients may depend on your patient mix—a company with pediatric patients may have a larger percentage of clinical patients and a company with ventilator patients would have a larger percentage of clinical patients. A company that has only oxygen concentrator patients may have a low percentage of clinical patients. Last, each clinical patient upon discharge must have a discharge summary in the client record and evidence that it was sent to the attending physician. 
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