Chest
Topics in Practice ManagementCurrent Issues in Home Mechanical Ventilation
Section snippets
NPPV
The rapidly expanding home use of NPPV using a nasal or orofacial mask provides an even larger opportunity to allow patients to transition to the home environment without the need of a tracheostomy tube. Portable, lightweight, single-circuit flow generators that are capable of delivering bilevel pressure support with mask leak compensation can actually provide high levels of pressure support near 30 cm H2O. This treatment initially emerged and quickly proliferated with the successful
Home Noninvasive Mechanical Ventilation Policies and Practice Standards
The practice guidelines were presented in a publication14 that was based on an expert consensus conference panel precipitated in part by the alarming increase in NPPV use for COPD patients requesting very expensive reimbursement from Medicare. These recommendations included provisions for patients with restrictive thoracic cage disorders and NMD, as well as for patients with severe COPD and hypercapnia/nocturnal desaturation despite oxygen use, and finally those with other primarily nocturnal
Home Invasive Mechanical Ventilation Policies and Practice Standards
One of the biggest obstacles that providers face in the provision of invasive HMV is simply a lack of strong, evidenced-based standards of care. As a result, local practice beliefs and reimbursement restrictions have produced marked regional variations. Unlike other home respiratory technologies (ie, home oxygen therapy and sleep disorder therapy), there is no standardized Medicare national coverage determination governing HMV, or even any local medical review policies or local coverage
Population of Ventilator-Assisted Individuals
Ventilator-assisted individuals (VAIs) are composed of a mix of adult and pediatric patients with a variety of underlying medical conditions contributing to chronic respiratory insufficiency and/or failure. Common disorders may include but are not limited to the following: spinal cord injury; NMD; chronic lung disease (obstructive and restrictive); bronchopulmonary dysplasia; and other birth-related anomalies contributing to respiratory insufficiency and/or failure.
There is very little accurate
Coding and Reimbursement
Although the home has been noted to be one of the lowest cost points of care for VAIs,17 the lack of published information and recognized standards of care leaves notable gaps in the coding and coverage methodologies. An addition to the current procedure terminology (or CPT) coding may provide some relief in tracking VAI patient services. The new current procedure terminology code 94005 (“Home Ventilator Management Care Plan Oversight”) can be used by physicians who are managing HMV patients.
The HMV Technology
In the 1980s, we saw the introduction of what most clinicians consider to be the modern portable or home mechanical ventilators. Most portable ventilators were relatively small and lightweight (compared to hospital equipment) and typically were housed in cast aluminum frames. Nearly all of the first-generation portable home ventilators used some type of simple bellows or piston design to generate the needed flow, pressure, and volume. Although considered somewhat basic and low technology by
More Than a Ventilator
The management of VAI in the home incorporates more than just a ventilator. Medically complex VAIs often depend on a myriad of medical devices and services to duplicate the care provided in the institutional setting. Commodities such as oxygen, air, and suction, which are available at nearly every bedside in the hospital, must be produced from various devices in the home. For many VAIs, their homes often take on the appearance of a hospital room. The extensive list of adjunctive medical devices
Critical Care to Home Care
Invasive HMV is arguably one of the most complex respiratory services delivered in the home. In contrast to many other home-care services, invasive HMV requires much more advanced decision making, planning, training, and oversight. Highly effective hospital discharge planning that includes well-choreographed interdisciplinary support is essential for long-term success.20 Physicians, nurses, professional therapies, home respiratory therapists, insurance case manager and, most importantly,
The Hidden Costs of HMV
Assuming the responsibility for the care and management of a VAI or other technology-dependent individual is a life-altering event for most families and caregivers. There are few available data that capture the myriad indirect costs associated with the care of VAIs in the home. These hidden costs include, but are not limited to, the following: lost wages for a spouse, parent, or child who stays home to care for the VAI; out-of-pocket costs of noncovered medical items and supplies; and the cost
Steps To Promote an Effective HMV Management Program
Although there remains an absence of recognized standards and objective science in this area, years of successful hospital discharge experiences with medically complex patients have produced a series of common-sense techniques that can help produce a smooth transition to home, as follows:
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Create a safe home environment. The patient's care and safety is central to the home management of any VAI. It is important to ensure that the home environment and caregivers can support the technological
Summary
HMV is an important yet somewhat complex area of medicine that requires appropriate attention and support from all stakeholders. A well-executed HMV program produces a safe and appropriate environment of care for VAIs while concurrently delivering to the health-care system a cost-effective and patient-centric system for servicing the clinical and lifestyle needs of technology-dependent individuals. Even Medicare and Medicaid services are now beginning to recognize this value, and pilot programs
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Cited by (40)
Home health nurses for children with invasive mechanical ventilation (IMV): Perspectives on gaps and opportunities for recruitment
2023, Journal of Pediatric NursingInfrastructure- and workforce capacity for the provision of health care to people with invasive home mechanical ventilation: A scoping review of indicators and norms
2023, Zeitschrift fur Evidenz, Fortbildung und Qualitat im GesundheitswesenMental health reported in adult invasive home mechanical ventilation through a tracheostomy: A scoping review
2022, International Journal of Nursing Studies AdvancesCitation Excerpt :The purpose of the present scoping review was therefore to close this knowledge gap in relation to people receiving invasive home mechanical ventilation through a tracheostomy. Home mechanical ventilation is a versatile and complex treatment area provided outside a hospital setting for people with chronic respiratory failure (Hind et al., 2017; Lewarski and Gay, 2007; Simonds, 2016). Both invasive (tracheostomy) and non-invasive (mask) ventilator treatment can be used in the home setting (MacIntyre et al., 2016; Park and Suh, 2020).
Chronic respiratory failure: Utilization of a pediatric specialty integrated care program
2017, HealthcareCitation Excerpt :Technologic innovation, coupled with a growing appreciation of the broader social contributions of individuals with disabilities, have allowed children with CRI to remain at home and integrate into their communities with life-sustaining mechanical support 1. The need for intensive supports (e.g., transtracheal or noninvasive ventilation, assisted cough, home nursing, parenteral and assisted enteral nutrition, and continuous monitoring) reflects a range of underlying conditions, including neuromuscular disorders, spinal cord injuries, parenchymal pulmonary diseases, and respiratory dysfunction (e.g., central hypoventilation), as well as a burgeoning population of children with complex congenital heart disease.1 Approximately 6/100,000 children in Utah in 2004 require transtracheal mechanical ventilator assistance2; authors extrapolated that an estimated 4000–6000 children receive ventilator support at home throughout the US.
SEPAR Year of the Chronic Patient and Domiciliary Respiratory Care. Points for Reflection
2014, Archivos de BronconeumologiaAcute and chronic respiratory failure
2014, Handbook of Clinical NeurologyCitation Excerpt :The technology is available with portable, lightweight, single-circuit flow generators that are capable of delivering bilevel pressure support with mask leak compensation at high levels of pressure support near 30 cmH2O. Invasive HMV is one of the most complex respiratory services delivered in the home and requires much more advanced decision-making, planning, training, and oversight (Lewarski and Gay, 2007). Not too long ago, therapeutic nihilism was governing the approach to the care of the patient with a NMD.
The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.