Too great not to share. We recently did a webinar for a closed group of potential telerespiratory therapists. Check out this case study involving a newborn, bubble CPAP, some great nurses, and a lot of critical thinking! This is how it’s done!
Date:
04-Dec-2019
The Vent Room Podcast: Episode #4
DRAGONBERRY: Welcome to The Vent room where respiratory therapists can come and get a little inspiration. I’m your host Dr. Tabatha Dragonberry. Our guest today is going to be Curt Merriman. He is the chief sales officer at rtNOW which is, essentially, the first turnkey respiratory therapy telehealth solution that I’m personally aware of. I think it’s an innovative way to bring respiratory therapy farther into the digital age. Curt, can you tell me a little bit about how the idea of rtNOW came about?
MERRIMAN: Oh, absolutely. Tabatha, thank you for having me today, I appreciate the opportunity and what you’re doing with The Vent Room. So back in 2016, as you mentioned, I’m a respiratory therapist. Myself and some of my other business colleagues were getting requests from our respiratory therapy staffing company to help staff rural hospitals and healthcare institutions when they’d have new admissions for COPDs going through an exacerbation. And, unfortunately, we did not have therapists just readily available to jump in their car and drive three and a half hours to go see those patients and then drive back home. So we came up with the idea, “Well, why can’t we utilize the respiratory therapists’ critical thinking skills and our unique skill set in a telehealth format to provide our knowledge in consultation remotely via our virtual video chat?”
So we initiated some of our planning in August of 2016. We opened up our first pilot in a small town in southwestern Minnesota, Sleepy Eye, and initiated with our critical access hospital there rtNOW telehealth. And we were there for about four and a half months, and during that pilot project we found success, and basically, acknowledged our concept was actually possible and achievable.
DRAGONBERRY: That sounds amazing. I know there’s several types of telehealth. You have provider to consumer, provider to provider, and remote monitoring solutions with that. Yours is more of a provider to provider, or also that, provider to patient?
MERRIMAN: Well, so we’re actually more of the live video conferencing synchronous mode. At this point in time, we’re primarily working directly with institutions whether they be small critical-access hospitals or skilled facilities that do not have respiratory therapists either available to them 24 hours a day and in some cases, they just do not have respiratory therapists available to them at all. We don’t intend nor do we think that we can replace the boots on the ground so to speak, of a respiratory therapist , but we have significant shortages. I think all of us are aware of respiratory therapy personnel across the country and, especially in rural America to recruit and retain individuals is a challenge.
So most of our work is done as live video conferencing. We’re communicating and working with the nurse or the provider at the bedside as well as speaking with the patient. At this point in time, we’re not in the home setting although there’re some new avenues coming about with remote patient monitoring that you had mentioned with some codes that may allow that to be a more successful advantage for telerespiratory to actually be seeing these patients in their homes to help eliminate hospital readmissions or, at least redu them.
So with the goal of using evidence-based practice, we’re always focused on those outcomes.
DRAGONBERRY: What have the outcomes been for the rtNOW services?
MERRIMAN: Actually, when we first got into this, we weren’t quite sure what we would come up with. And what we found is, even during that first pilot study of the four and a half months, that particular hospital identified– the nurses identified, themselves, three patients that they would have transferred out that they were able to keep because they utilized rtNOW, the telerespiratory therapist, to help them achieve successful non-invasive ventilation on patients and keep them there at the hospital and not having to transport them out.
DRAGONBERRY: Which is great for that small-world community because, then, they’re keeping the money within their organization not having to ship those patients out.
MERRIMAN: Exactly. And it’s not only just the money, but the community hospitals really play an integral part of that community. I mean, they’re typically one of the larger employers within that community, and they have family members that they’re taking care of. And one of the examples that we talk about in some of our studies happened over their Christmas holiday, and a COPD patient that exacerbated was able to be kept there on-site at their local hospital. The family was able to visit them without having to travel 60-plus miles to a larger tertiary care facility.
DRAGONBERRY: And that, again, goes to that holistic care of taking care of not just the patient, but the family and keeping them within their community because they feel safe.
MERRIMAN: Exactly.
DRAGONBERRY: With your services, are they being sought out by organizations now? Are there organizations saying, “Hey, we are needing to fill in these gaps.”
MERRIMAN: It is starting to occur that way because, as you had mentioned, we believe we’re the first very specific telerespiratory providers in the market place starting back in 2016. And it’s taken a few years just to get people aware of it, and we’re now actually getting some organic word of mouth growth with people hearing about the service and about telehealth being able to be provided for respiratory therapy patients and that. So it’s starting to come through, and we’re happy to see that. It’s been exciting.
DRAGONBERRY: So on your team, how many respiratory therapist do you have at a time or taking care of these remote patients?
MERRIMAN: Oh, great question, Tabatha. So we have 21 respiratory therapists that are providing services 24/7, 365, for our rtNOW. Those 21 therapists are typically working in point positions in various hospitals, and then, do extra above and beyond time working with rtNOW and the telehealth aspect of it. We do have a couple of people that are going to school, and rtNOW is their primary employment as well. At this point in time, with our call volumes, we typically have one therapist on at a time to cover the calls that may be coming in. But we do have redundancy and backup plans in place, so if there’s multiple calls occurring at once, that we have other therapists that we can make available to initiate and take those video chat calls.
DRAGONBERRY: In doing some research for the show, I found an American Academy of Ambulatory Nursing has a telehealth certification. I also found that there was a certification for telehealth coordinators. Just like any profession, there are different organizations, such as the American Telemedicine Association that also accredit courses. Do you believe that RTs could have their own telehealth certification one day.
MERRIMAN: I definitely think so. It does take a unique set of skills to successfully do telehealth as a respiratory therapist. It’s a different type of patient care, where we’re used to being the hands-on in the room, can see, talk to the patient, be able to assess what’s happening in the whole environment just by walking into the room. And it does take a little bit of additional training that we provide for our staff, heightening their awareness of being observant when they’re asking the nurse to move the technology, we’re using an iPad on a stand, and moving that around in the rooms. We have a good view of the patient environment, the patient, the monitoring, what’s going on in the surroundings there. And then heightening their communications skills to asking more in-depth discerning questions so that we can get a better picture. We’ll typically also have the ability to remote into the facilities EMR to get histories and that, but when we’re dealing with the emergency department where there’s not a lot of time involved and it’s more of a “just in time, we need your assistance right now,” we’re doing a lot of communication with the nurse and the provider and the patient right there in the room.
DRAGONBERRY: So with that experience and education, if there is a respiratory therapist that’s kind of looking at this as an option for their career tract, what do they need to be doing now? What education or any additional skills that they could be growing now, so that they can say, “You know what, in one or two years, maybe my old bones can’t do the floor care anymore,” or just people want to have that option of working from home because I know on social media I’ve seen questions about that, and people are always like, “I’m looking to transition, what can I do as an RT from home?” What skills do they need to start growing now?
MERRIMAN: Sure. There is information with– you had mentioned the American Telehealth Association and some others that have information about kind of enhancing your skill set. It’s still something that’s relatively new because telehealth is still a very new field in healthcare for us and specifically for respiratory therapists. One of the things that I can encourage is if you do go to our website we do have a section on there called the rtNOW Bullpen, and basically it’s a community where people can kind of talk with one another, learn a little bit more about telehealth. There’s also a LinkedIn and facebook area which is just under telerespiratory that, again, is not specific to rtNOW but is just for anybody interested for colleagues and peers to discuss amongst themselves and get ideas, share ideas. And hopefully as that community grows and people that are doing more of the telehealth themselves can be sharing their experiences also through that to get the backgrounds. And I do see that we’ll find more certifications coming available.
DRAGONBERRY: My aunt is a remote-nurse-case manager, and she holds licenses in 14 different states where she manages cases. How does the licensure work for the rtNOW therapists?
MERRIMAN: Very similarly. There’s really not at this point in time a telehealth reciprocity for a therapist to see patients in different states without requiring them to seek those licensees, so as I mentioned, we have a staff of about 21. The majority of our therapists have multiple-state licenses, and when we take on a new state will not only have our therapist gain a license for that state, but we’ll also do recruitment within that state itself of therapists that are currently working there. And that’s part of what the bullpen is all about, it’s just kind of prepping as things grow and expand. Right now, our company is Minnesota, Wisconsin, Missouri, soon to be Michigan. And as we gain more states, we’re actively recruiting and looking for therapists that have an interest and have the skill sets that we feel are important.
DRAGONBERRY: So I know that you were saying that in your education, you’re kind of focusing on that heightened communication and being able to observe differently because you’re not in that environment. What kind of education and training and hardware is supplied to somebody that is a new hire, as your company is expanding?
MERRIMAN: Great question. So we have online training that we’ve put together, that when we have a therapist that we’ve vetted and we feel that both they and our leadership team feels like it’s a good fit, they’re sent a link for some online training and education, which is just some basic information. It can be some things as simple as, what is the lighting like in the room that you’re going to be doing your video chatting, their Telehealth conferences? Making sure that it’s HIPAA compliant, PHI compliant. So that it’s a secluded area, at least an area that can be closed off so that people aren’t hearing information that they shouldn’t be hearing, or seeing it as well. Just kind of, I think I mentioned, the lighting, speaker sound, that type of thing. Just from a technical aspect, make sure that everything looks professional, sounds, and is professional from that standpoint. So they go through that training, some education on some of the communication skills to help heighten their questions that they might be asking. And then they do a one-on-one. Everything that we do is web-based, or browser-based, so they get our system set up on their computers and then we do some one-on-one training just to make sure that they’re comfortable, everything is functioning, they know how to navigate things through. One of the things that we do, because the therapists obviously have not set foot in any of these institutions, is when we on-board a customer, we’re seeking information from an internal champion at that facility to give us information on the respiratory equipment that they’re using, any of their respiratory medications, what’s in their formulary. So that when the therapist is seeing that patient, we’re making recommendations based on the equipment, the best practices that they have in place, any protocols they have in place, that type of thing. So we’re functioning just as if we were there on site.
DRAGONBERRY: I can imagine it in my head. I think it’s just the next step. I kind of think like Star Trek, you’re going where no respiratory therapist has ever gone before, right?
MERRIMAN: [laughter] That’s a great analogy. That’s fun.
DRAGONBERRY: Because I’m just imagine just having to work through that, and you’re seeing a patient and caring for them from however many, either thousands of miles away or hundreds of miles away, and that you’re impacting and affecting the care. And the facility’s happy to have you there and they’re wanting to have you there, even though you aren’t physically there.
MERRIMAN: Correct. There’s often times skepticism within the organization when they first start with our telerespiratory service. And many times, the nurses are wondering, well, how can you actually do this and really be of service to us via video chat? And after the nurses experience or providers experience the calls, the comments that we get are, “Wow. I didn’t realize how much you could actually do via a video chat and helping me at the bedside and just giving me the confidence that I needed to care for that patient in that crucial time when– oftentimes, their is an increase work of breathing and they’re dyspnic. They’re just having a terrible time and the amount of stress in that scenario is, oftentimes, quite high, and we can just help alleviate that with a therapist right there walking through with them.
DRAGONBERRY: Can you walk me through, like a consult, one of the RT-now-therapist may encounter?
MERRIMAN: Sure. So the two primary types of calls that we’ve experienced since we’ve started this is NIV or a new respiratory patient being admitted to the facility and the telerespiratory therapist performing an RCAT, a respiratory care assess and treat– or however you might term it. Each facility can name them a little bit differently, but. Basically, we’re viewing the medical record, looking what their histories are, what the medications they’ve been on, and their I’s and O’s, their current status, X-rays, all the type of information from a clinical standpoint just like you would be as a therapist in the facility, reviewing that before you go into the room. We’d ask the nurse, “Okay. Let’s go ahead and bring us to the room via our technology and arrange the iPad so that we can communicate easily with the patient and have a discussion with them,” to find out occupational exposures, just like you would if you were walking in the room.
Most of the time– at this point in time, we’re relying on the nurse’s auscultation techniques. And one of the things that our therapists are doing is asking, again, a lot of discerning questions. As many of us know, that one person’s definition of a wheeze is not the same as the next person sitting by them. So the therapists are asking some really discerning questions about what that wheeze or that particular breath sound actually sounded like to determine what it is that they’re looking for. There are technologies, Bluetooth stethoscopes that we’ve done some evaluation on and we’ll probably be deploying them soon, actually. But in the meantime, we’re just relying on the nurse’s communication with us and what they’re hearing. And we’ll then make the recommendations remotely in the medical record as if we were a therapist working right there at the bedside and make the recommendations for medications, treatment modalities, frequency, that type of thing, any airway clearance that may be required, supplemental oxygen, all those kind of things.
DRAGONBERRY: So we all know that advances in healthcare move faster than government legislation. Where you guys are working now and operating, is there any government regulations that it’s making it easier to provide this service or is it just such an untapped market that we’re kind of cowboys figuring it out as we go because there isn’t regulations?
MERRIMAN: Yeah. That’s a great question. So so far, there really has not been a lot of regulations that we can follow from a respiratory therapist standpoint and reimbursement there. There are currently a couple of different pieces of legislation in DC, the BREATHE Act and the CONNECT ACT, probably the two most prominent ones. Both of those acts, if they get forwarded on and pass, would allow and identify a respiratory therapist as being a telehealth provider. And that would open up something significant doors for us to be able to really take what we’re doing to the next level, and it also would identify the patient’s home as a location that we could be providing those services to those individuals. So again, by doing the virtual visits, we could help do that chronic disease management, education, self-management care, and just ensuring that the patient safety in their home surroundings and keep them out of the hospital and in their own environment, can truly learn better about their disease process and how to manage it better, and again help reduce the hospital readmission’s. There are some new things that have changed in this past year with remote patient monitoring, with some codes that I think are really going to play into the whole telehealth process. So it’s allowing respiratory therapists to be a part of that and seeking out in obtaining data from a patient that we can use those early indicators for them going into having some difficulties in trying to get them before, I mean, or contact them before they’re being rushed to the emergency room.
DRAGONBERRY: With some of those acts, I know previously that they required a bachelors degree. Do you know the ones that are currently pushing through with the CONNECT or BREATHE, is it saying that that respiratory therapist needs to have a bachelors degree to be considered for the reimbursement purposes?
MERRIMAN: Well, neither of those acts have a– because they haven’t been passed yet into law, those kinds of regulations and rules will be written after the fact. But what we do know is that typically, for any type of reimbursement from a healthcare professional, the standard practice is to have a Bachelors of Science degree, whether it’s specifically in respiratory therapy, or it may be just a Bachelor of Science in some other health-related degree along with a respiratory therapy diploma that they have and a degree as well. So those details have not been worked out, but it’s pretty much the standard practice that it would require a Bachelors of Science or greater. Masters, PhD, that type of thing.
DRAGONBERRY: So I know a while back, I actually took a telehealth course, and the professor mentioned a company that was in New Zealand, and they hired American doctors, relocated them overseas to provide telemedicine in the US. Because when it’s nighttime in the US, it’s daytime in New Zealand. So the whole thought process and their promotion was that, you’re always going to get that fresh doctor versus waking somebody up in the middle of the night. And we should be sleeping, naturally, I know that night shift has wreaked some havoc on my body. So what do you think on that whole aspect of that Innovative–? We’re taking telehealth, and now it’s an even totally different innovative thought.
MERRIMAN: Well, that’s actually quite interesting, and I’ve read about some of that as well, and it does make some good sense to be able to do that. A lot of it is really getting it to kind of come down to the logistics and the reimbursement and the fiscal ability to make that happen. Because we are a global world now, we could be providing those kinds of services with providers here in the United States for people on the other side of the world. Again, that would be the day shift there, the night shift here and vice versa. And it could work out quite well. So far, with our experiences with the therapists that are sometimes being woken up in the middle of the night, we have not had areas of concern with that. The vast majority of the calls seem to come in more on evenings and on day shifts and on weekends. Some of the night shifts, but not as many as I think we initially anticipated.
DRAGONBERRY: That’s interesting to know because I feel like– I don’t know, when I worked night shifts, 2:00 AM seems to be the magic hour.
MERRIMAN: Well, when we do get the nighttime calls, that’s about the time that they do come through, you are correct.
DRAGONBERRY: I think it’s interesting how those types of trends, you notice them when you’ve been working in the industry for a while.
MERRIMAN: Yes. Exactly.
DRAGONBERRY: Curt, thank you for joining us here at the vent room. It’s great to see RTs are making strides in telehealth and being successful and showing that they’re other opportunities, and that we can move to the bedside but in a digital perspective.
[music]
MERRIMAN: Well thank you. I’ve been a respiratory therapist for 40 years, and I still believe that this profession offers many opportunities in– the telehealth is now one of the newest forms that I think is certainly going to be in the forefront for many years to come. And I appreciate you reaching out to me and taking the time to chat about respiratory and how RT’s , and definitely take a part in the continuum of care.
DRAGONBERRY: Thank you, Curt
By Chuck Stadler, Jr – President and CEO of rtNOW.
One of my nursing instructors/mentors (Mona White) told me years ago, “The gauge of a great nurse is not to know everything, rather to know what questions to ask and where to find the answer”. Nobody can be comfortable and knowledgeable with every aspect of nursing, and anyone who claims to be is crazy. Nurses have all been taught to lean on their clinical peers for guidance. A respiratory therapist has always been a pivotal member of the clinical team, offering specialized respiratory expertise.
Using Minnesota as an example state1, in urban areas 1 respiratory therapist has the potential to serve 2,647 patients. In small rural towns, the ratio is 1 respiratory therapist to 5,746 patients. On the far end of the spectrum, in isolated rural areas the gap widens to an enormous 1 therapist to 29,143 patients. During the 2018 – 2019 data collection period a projected 104 openings across the state with a supply of 81 graduates to fill these openings2.
This is one example of respiratory therapist shortages that continue nationwide. They are a problematic reality in today’s healthcare landscape, but current technology can also provide an answer.
Whether you have partial respiratory coverage or no coverage at all, telerespiratory care is emerging as a viable way to increase the number of medically complex patients your staff can successfully handle, while capturing PDPM dollars. Nurses can quickly connect with a respiratory therapist via phone and video chat, who can then consult on equipment, perform respiratory assessments, make recommendations for treatment plans (i.e. NIV, CPAP, trach care), and serve as a supportive bedside resource to nurses, providers, and patients/residents. Once telerespiratory is integrated into a culture, experience has shown that it can be key to avoiding transfers. For examples of this, look at these case studies from rtNOW.
And the good news is that it makes financial sense. For all the change that is happening there are 9 stackable NTA codes3 specific for patients with respiratory comorbidities (Chart 1). As you know, there are many other codes that would be also associated with some of these patients with multiple comorbidities. PDPM provides a unique opportunity for skilled nursing facilities to grow their respiratory resources via telerespiratory care while capturing PDPM dollars.
If your organization is planning to take on the medically complex population, you will start to get pressure from all sides on how to care for them properly. It may be that your organization has been fortunate in finding and maintaining a respiratory therapist on day shifts, but what about the nights? Your evening/night shift clinical team probably has less experience and different staffing ratios than the day shift. Who are evening/night shift team supposed to use for guidance through the night? The administrator? DON, ADON? Will they wake up one of your day shift RT’s? Or will they continue to transfer the patient to the hospital? These are important questions, and thankfully we now have an answer.
I would like to propose that an easy solution is to give them a team of licensed RRT’s available with the touch of a button via telerespiratory. Pricing packages range between $4-5/hr depending on the amount of coverage desired. A small price to pay to add a knowledgeable team member at the immediate time and place your staff has a need.
References:
A couple of weeks ago we asked our rtNOW agents to give us some examples of calls they have had. It was exciting to hear agents come out with story after story of how rtNOW helped staff and patients at hospitals and in nursing homes. Particularly exciting to us were the transfers avoided, and how well our agents interacted with remote staff members as part of the team.
Here is a compilation video of some real-world case stories in which our telerespiratory therapists saved the day.
A wise man once said, “Let another praise you, and not your own mouth”.
With that in mind, we would like to offer you some quotes from nurses who have worked with our telerespiratory therapists at rtNOW on a daily basis. These quotes are taken from our nurse testimonial video.
Lynnae Pelzel:
“rtNOW has benefited us in a rural setting dramatically.”
“They can troubleshoot for you or they can help you out with a COPD exacerbation or whatever the emergency is or even a non-emergency.”
“We don’t have many resources and going to someone who specializes in that area really causes comfort for the nurses and helps out the needs of the patient.”
“Our team now is beneficial for any institution especially a small rural setting where we do not have our therapists on staff 24/7
It’s very easy to use as nurses and they make the patients feel really comfortable too.”
Brittney Green:
“In our small facility, we don’t always have a respiratory therapist here so using rtNOW we can call them on the iPad in the emergency room or in a patient room…”
“They show you everything that you’re supposed to do their kind of hands-on right there for you to look at and talk to.”
“I’ve used it in the emergency room, I’ve used it in patients rooms in specific situations.”
“They can help readjust settings and things like that that I don’t specifically know because we have so much that we have to know.”
It’s really nice to just be able to ask questions they never make you feel like you’re asking a dumb question or anything like that.”
“rtNOW has definitely avoided transferring patients especially in our small town area”
“We don’t have a respiratory therapist in-house and you might not have as knowledgeable staff at the time or the doctors on their way but they’re not here yet you’re going to just click and pull them up and ask any questions at all that you have.”
“Its direct patient care they’re right there on the screen can talk to you face-to-face.”
Katie Bloedow:
“They know everything about the equipment that we have in house even if they’ve never stepped foot into our hospital.”
“Using rtNOW is extremely easy it’s a matter of picking up the phone and push a green button on an iPad.”
“Whether or not they should, you know, be on the BiPAP or I need an extra set of eyes to help me assess their breathing to give us recommendations as nurses or even to the physician…”
“I feel that with the support that they give us 24/7 365 that I’m more comfortable and competent in our equipment and more confident in my skills as a nurse.”
“I’ll have a patient that maybe isn’t doing so well and then I’ve used rtNOW and their recommendations and I’ve seen my patient turn a corner for the positive.”
“We also then can provide that service right here in-house where maybe a transfer would mean that they have to go somewhere else where someone is in-house to provide that.”
“I have used rtNOW and I think it’s awesome.”
Naomi Weiss:
“I feel like if I ask them a question they already kind of know what I’m gonna ask and they’re prepared.”
“rtNOW has absolutely made me feel more confident in my job.”
“They’re very supportive they’re very confident in what they do.”
“We’ve had several instances where in the middle of the night we’ve had issues with the equipment the mast not fitting properly just questions about a patient’s status and they’ve always been very helpful.”
We clearly remember traveling to conferences in 2015 ready to sell rtNOW to hospitals and skilled nursing facilities as a telehealth solution for respiratory care. Little did we know at the time that we would spend years educating providers about what telehealth is, let alone how our solution solves many of the problems with respiratory care that rural organizations face.
Breaking new ground in healthcare is a strange and wonderful process. There is an excitement for the initial idea – a vision of how great healthcare could be if you can simply remove barriers. Then comes a pilot, where you work closely with a facility until you iron out the operational details, declaring to yourself and the world that it can be done. Then comes the first sales cycle including a definite period of time where you struggle simply to convey the concept to others.
And then there comes a point, years later, when you are recognized by the leaders in your field as the pioneers of a solution that will propel everyone forward.
This past week we were recognized by the AARC for our efforts in the creation of telerespiratory in the latest edition of the AARC Times.
This is a wonderful article, and it goes through quite a bit of our history and experiences from both the leadership and staff.
Since the interviews for the article occurred we secured our first client in another state – Missouri. And with it, we had more “firsts” to work through.
We have a culture here at rtNOW. It is a culture of innovation. It is a culture of making “it” happen.
When we meet for our executive meetings, each quarter we go over our core values. These values guide every aspect of who we are and what we hope to achieve. We set a vision for the future, and our values guide that process. I believe it is appropriate to reflect on these values today. Values such as:
We innovate simple solutions.
We decisively improve.
We are respiratory experts.
We are professionally approachable.
We make it happen.
We follow through.
We empower people.
However, as we begin to be recognized as the world’s leading authorities in the emerging field of telerespiratory, one seems to ring louder than the rest:
We are respiratory experts.
rtNOW was created by respiratory therapists. A group of experts who were, and are, the best in their field. And as such, rtNOW is more than just a business, it is a passion, and an extension. It is an extension of some of the best therapists in the world to deliver the best possible respiratory therapy to patients. And a passion to see the patient have the best care possible. And more than anything, out of a desire to empower respiratory care at every point along the way.
It is good to see that the passion we have is catching on and empowering people.