All About Compliance – Advocate Home Care Products

Consistent follow-up, productive partnerships with sleep labs, and high tech monitoring all lead to an overall Medicare CPAP compliance rate of 63% at Advocate (http://www.Advocatehealth.com).

Earning a high compliance rate for Medicare beneficiaries— a patient population that can be particularly challenging—is no easy task. Illinois-based Advocate is able to hit the lofty percentage thanks to old fashioned human interaction and sophisticated technology.1

The financial stakes are high, because without at least 90 days of objective compliance data, providers do not receive reimbursement from CMS. On the other equally important side of the coin, poor compliance equals unhealthy patients.

Nadia Rallo, CPAP coordinator at Advocate, relies on the ResTraxx Online System from ResMed for wireless compliance monitoring—call it the high-tech portion of the compliance equation. ResTraxx allows Rallo to remotely monitor patients and check on them at a glance, a process that can quickly identify causes of noncompliance.

A function called exception reporting aids in the management of multiple patients by identifying those who fall outside desired thresholds for usage or mask leak. From there, Advocate staff members can focus efforts on those who require intervention. “We also have a system which allows us to enter patients in a database and pull follow-up reminders for the patient,” says Rallo. “As soon as that patient gets set up, I put in a 31-day reminder to follow up, plus a 45-day and a 60-day reminder. Using this with the the ResTraxx system has really made the difference for us.”

If a problem crops up at 31 days, Rallo immediately sends a respiratory therapist to the patient’s home to correct any mask or discomfort issues. “Follow-up is the key with these patients, as is communication with the sleep lab and the therapist,” says Rallo. “Everyone works hand in hand, and it is one big team that is focused on patients.”

As a large scale HME in the Midwest, Advocate Home Care Products maintains that focus requires an unwavering dedication that stretches to sleep lab partners and referral sources. Darrell Swiniuch, respiratory care manager at Advocate, acknowledges that patient challenges are numerous: discomfort, resistance, poor engagement, lack of awareness/education; documentation; unreliability of patient reporting; and rigorous payor requirements all factor in.

By following a model of partnership and communication with sleep labs, along with regular follow-up and exceptional treatment, Advocate has overcome these challenges. The results are improved patient health outcomes, positive impacts for comorbidities, and potential cost savings for payors.

Wireless Monitoring a Priority

When Swiniuch and Advocate staff members sought to boost compliance, they went on the hunt for better technology. “We needed some type of wireless communication to make it easier, because there is no way we can go out to all the patients’ homes and do these downloads,” says Swiniuch. “There is a great relationship with the patients going to the sleep labs, and when they do their follow-up visits at the labs, the lab technicians can download from the machines. We also needed a system such as ResTraxx to keep an eye on these patients.”

Prior to electronic monitoring, it was difficult to see what patients were doing on a day-to-day basis. It was labor intensive and costly for therapists to visit the home, and often inconvenient for patients to make trips to the doctor’s office. Fortunately, a wireless system of remote monitoring was introduced to boost CPAP compliance, while making the retrieval of data much easier.

When patients receive the technology, Swiniuch reports that there is not much they need to do. “We set up the machine and put the ResTraxx unit on it,” says Swiniuch. “All we have to do is register it to the ResMed site, and from thereon it is just communicating with the machine. We can get the data any time of the day. With all of our sleep labs involved with ResTraxx, we can issue them a pass code for only their patients if they would like to view information online to help with compliance.”

Many ResTraxx users appreciate at-a-glance reports and exception reporting, while Swiniuch prefers the month-to-month information that indicates compliance. “I look at the therapeutic report which provides the number of hours, the AHI, and a report of any mask leak,” he says.

ResTraxx uses AT&T’s GSM network, similar to Blackberry data, and every afternoon information is transmitted from the patient’s bedroom to the cell tower. From there it is encrypted, put into a server, and downloaded into a Web site portal that Advocate can access. “The actual unit is about the same size as a cell phone that fits on the back of a CPAP machine and basically acts as a conduit,” says Rob Suter, territory manager for ResMed, Chicago. “When you plug in the CPAP, it powers up the ResTraxx unit to signal and send information to the cell tower.”

Comfort Equals Compliance

To further support compliance, Advocate takes advantage of clinically validated comfort technologies. Research shows that auto-titrating devices have improved long-term compliance, but getting patients comfortable with treatment is an ongoing challenge. Advocate realized long ago that technology, combined with calling, emailing, and visiting, is the only real way to ensure that patients are using their equipment.

The technology preferred by Advocate is under San Diego- based ResMed’s S8/S9 umbrella. Advocate uses APAP machines with expiratory pressure relief (EPR) technology on the majority of their patients. EPR enhances patient comfort and makes exhaling against fixed pressure easier. ResMed APAP machines have three lines of defense against non-compliance: 1) responding with aggressive pressure increases in the midst of flow limitation to the upper airway, snoring, and apneas; 2) auto-titrating technology that continually adjusts to deliver the lowest therapeutic pressure necessary; and 3) responding to snores and the severity of such events.

Using APAP technology combined with wireless monitoring, plus the excellent follow-up implemented by Advocate, is a direct path toward patient compliance.

It all adds up to what has become a successful marriage of the old school (telephone) and the new school (ResTraxx and S8/S9 technology). Rallo says you can’t have the high tech without the low tech, because that human connection and caring seals the deal. “Most people are very receptive when I call,” says Rallo. “You’ll always have the occasional one or two that don’t want to be bothered but, quite honestly, at the 31st day when I call— especially if they are not doing well—they do not find me intrusive at all. I would say that 99% of them welcome my calls.”

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ResMed officials are building their compliance case with clinical trials. One recent trial involved 50 OSA patients using the S9 every night in place of their own CPAP for 4 weeks. The summary of the compliance study showed patient daily usage increased by up to 30 minutes on average with S9 devices. Visit http://www.clinicaltrials.gov and reference ID number NCT01013207 for more details.

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ResTraxx at a Glance

Web-based compliance monitoring allows users to

  • check on patients at a glance;
  • zoom in for more information; and
  • quickly identify causes of noncompliance.

Exception reporting enables you to manage multiple patients while helping to:

  • identify those who fall outside desired thresholds for usage or mask leak;
  • focus efforts only on patients who require intervention; and
  • act as a value differentiator in a competitive market.

ResTraxx can add value to referral business by:

  • providing referral partners with proof of higher patient compliance due to improved patient care;
  • improving productivity and managing patients more efficiently;
  • transferring compliance and efficacy data either daily or historically, for access via Internet;
  • saving time and money by adjusting therapy settings remotely;
  • changing pressure and comfort settings without data cards or home visits;
  • accessing coverage through AT&T’s GSM network; and
  • accessing patients’ information anytime and everywhere.

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Case Study
Compliance: From 5% to 73%

The story started a few years ago when a man with Down’s Syndrome came to Advocate via referral for an initial consultation. The man had already tried CPAP and failed due to anxiety and obsessive compulsive disorder. The patient ultimately had a tonsillectomy, which worked for a while. However, after a few years the patient started gaining weight, began snoring again, and became extremely tired at work.

When a primary care physician referred the man back to Advocate for a PSG, the hope was to alleviate his tendency to fall asleep at work. With PSG results showing an AHI of 98, therapy began in April 2010 with a ResMed S8 II AutoSet—with a pressure range of 16 to 20 centimeters of water pressure (CWP), and an EPR setting of 3. The patient, his family, and group-home staff underwent patient education and training on proper equipment use.

In June 2010, Advocate downloaded compliance data and found the patient was only using the machine for more than 4 hours per night 5% of the time. His Epworth score was still high at 17 out of 24, and the patient was still sleepy. Advocate’s respiratory therapist, Tracy Kinlaw, RRT, recommended a bilevel rescue, and the patient was placed on ResMed VPAP, with pressures set at 19 over 15 CWP.

A subsequent download in August 2010 yielded 18% compliance, with an Epworth score of 10. Pressure settings and machine mode were adjusted to VPAPAUTO at 20/10 CWP with pressure support at 4. Yet another download in October 2010 reflected a positive compliance jump to 73%. AHI went down dramatically from 98 to 15, with an Epworth of 7 out of 24, within normal range. In addition, the man lost 14 pounds, reducing his BMI of 42.6 to 39.4.

From treatment initiation and subsequent bilevel rescue, Advocate’s intervention consisted of regular data review, four home visits from respiratory therapists for mask re-fitting and re-instruction, plus cooperation with the family. Aside from the objective measures of significant improvement, Kinlaw’s personal interactions with the patient reflected a positive impact. “When the patient’s family first brought him to visit me, he barely spoke,”says Kinlaw.“He was so quiet and unresponsive, almost like he was falling asleep in his chair. The last time I met with him he was very animated and interactive. He was a completely different person.”

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1 Group A: n=55 patients

  • Discontinued therapy—attempts made at therapy but treatment ultimately was discontinued at or before 90 days with a physician’s order or AMA (against medical advice).
  • Group B: n=93 patients: Compliance maintained for a minimum of 3 months, per Medicare standards.

Total n=148 patients over a 4-month period

  • 62.8% (Group A): Overall patient compliance, including those that discontinued therapy early.
  • 90.75%—(Group B): Those patients that accepted and maintained therapy for a minimum of 90 days.


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