Executive Summary: Respiratory Care Practitioners in an Evolving Health Care Environment

INTRODUCTION

BACKGROUND

LITERATURE REVIEW

Evolution of Respiratory Care Practitioner Clinical Practice

Structural Models for Respiratory Care

Value of Respiratory Care Practitioner Services

Conclusion from the Literature Review

AARC MEMBERSHIP SURVEY

Data and Methods

Results and Discussion

STRUCTURED INTERVIEWS AND CASE STUDIES

Interview Protocols

Selection and Characteristics of Interview Subjects

Structured Interviews of Employers

Case Studies

Results and Discussion

SYNTHESIS AND STUDY CONCLUSIONS

Key Take-Home Messages

Implications for the Future

INTRODUCTION

The Lewin Group was contracted by the American Association for Respiratory Care to evaluate changes in the roles of respiratory care practitioners (RCPs) due to the advent of managed care and other health system changes. Respiratory care practitioners, including both respiratory therapists and respiratory therapy technicians, work to evaluate, treat, and care for patients with breathing disorders. The purpose of this study was to evaluate shifts in respiratory care practice in the context of the changing health care system and market dynamics. The main research questions of this study were:

• What is the value added to the health care system by expanding the traditional role of RCPs?
• How has the role of RCPs evolved in traditional (hospital inpatient) settings?
• In what types of non-traditional settings (i.e., outside of the hospital) are RCPs providing health care services and what is their role in these settings?
• What skill sets do employers in the marketplace require for RCPs?

The study consisted of three distinct components, including a literature review, an AARC membership survey, and structured interviews and case studies.

• Literature Review. The literature review focuses on three areas: 1) the clinical economics of respiratory care, particularly the cost-effectiveness of clinical outcomes generated by RCPs; 2) the clinical activities of RCPs in the marketplace and how these activities have changed over time; and 3) the policy context of allied health professionals in the evolving managed care marketplace.
• AARC Membership Survey. The purpose of the surveys is to: 1) document RCPs' involvement in delivering high quality and cost-effective services to respiratory patients and 2) understand the changing demand for RCP skills. We surveyed by telephone 471 AARC members, including RCPs and employers of RCPs.
• Structured Interviews of Employers of Respiratory Care Providers and Case Studies of Cutting Edge Respiratory Delivery Systems. The purpose of the interviews and case studies was to analyze individual employers of respiratory care providers' perceptions of the value of RCPs, necessary skill sets, and the structure of alternative delivery systems.
  • The structured interviews enabled us to obtain perspectives, beyond those of the traditional AARC RCP membership, from health employers of respiratory care providers, on required/desirable respiratory care skill sets, and the relative advantages and disadvantages of RCPs versus alternative providers, particularly in the context of new health delivery and financing models.
  • The two in-depth case studies identify and describe the role of RCPs in newly emergent care delivery models, which are influenced by managed care. Through a series of telephone interviews, we talked to individuals involved in a range of pertinent activities across the delivery structure and spectrum of care for each of the selected sites.

This Executive Summary reviews each chapter of the main body of this report. Additional details on any section can be found in the appropriate chapter of the report. A synthesis of this study's main findings can be found at the end of this Executive Summary.

BACKGROUND

The US health care system is experiencing dramatic change. The rapid rise of managed care is perhaps the most noted change that has occurred, but increasing emphasis on cost and quality of services has catalyzed system-wide shifts in health care practices and payment methods. This dynamic environment poses challenges to the traditional roles of health care professionals. Private market forces and public policies have a great deal of influence over health care in the US. Both of these influences shape how, where, and for whom health care dollars are spent. They also play a role in determining who can provide health care services.

Health care providers, including respiratory care practitioners (RCPs), must evaluate and respond to the market forces and policies shaping demand for health care services. Exhibit 1 presents some of the key public and private sector forces influencing the health care system. These factors will create new roles and responsibilities for RCPs. By adapting to the needs of the health care system, RCPs will be able to help secure their future roles in the health care marketplace.

Exhibit 1: Private and Public Sector Market Forces
Important private sector market forces include:	Public policies and regulations influencing respiratory care include:
Managed care - Changing practice and payment systems impact health care	Public Managed Care - Governments are turning to managed care as one potential solution to curb growth in health care costs
Consolidation - Fewer organizations have increasing control over the health care market	Medicare Reimbursement - The provision of specific services can be influenced by Medicare reimbursement regulations
Alternative Care Settings - Greater numbers of services are being provided in outpatient or subacute settings	Licensure - Professional licensure can provide a mechanism to protect patients from unqualified practitioners

LITERATURE REVIEW

The first component of this study consisted of a literature review. As illustrated by Exhibit 2, the purpose of this literature review is to evaluate shifts in respiratory care practice in the context of changing health care market dynamics. Such market dynamics impact all aspects of respiratory care, including RCP skills and practice settings, care delivery models, and the need to measure respiratory care outcomes. In order to succeed in the evolving health care marketplace, RCPs must be able to demonstrate their value to the system.

Exhibit 2: Roadmap to the Literature Review

Evolution of Respiratory Care Practitioner Clinical Practice

The role of the respiratory care practitioner has changed over time, and is continuing to change in response to shifts in the health care environment. The literature on respiratory care reveals that RCPs must develop new skills, take on additional responsibilities, and seek job opportunities outside the traditional hospital practice setting. Furthermore, RCPs need to evaluate respiratory care education programs to ensure that future RCPs learn the skills they need to succeed in the health care system.

Some of the important skills and responsibilities of RCPs include:

• Clinical Decision Making - RCPs use clinical decision making to assess patient health, recommend medications, and design, implement, and modify treatment plans.
• Case Management - RCP case managers can help lower costs by reducing emergency visits through better coordinated care and education.
• Patient Education - Managed care organizations and other providers seeking to control costs without sacrificing quality have begun to recognize the value of patient education as a therapeutic tool.

Another important aspect of RCP clinical practice is the respiratory care site of service. As the locus of respiratory care services shifts from the inpatient setting to both subacute and outpatient settings, RCPs are finding job opportunities in these alternative practice settings:

• Subacute and Long-term Care - Patients being treated in subacute facilities would otherwise still be in the hospital, and therefore have needs for many of the same services.
• Physician Offices - Physicians are finding it useful to have an RCP in-house to assist with diagnostic testing and provide education and training.
• Home Health Care - With heightened focus on controlling health care costs, both public and private payers are viewing home health care as a more viable alternative than in the past.
• Sleep Diagnostics and Monitoring - RCPs are well poised to take advantage of the growing market for sleep services since many sleep disorders are closely related to respiratory conditions.

Structural Models for Respiratory Care

Health system change, specifically pressure on health care organizations to both contain costs and improve quality, have forced organizations to focus their attention on finding the most cost-effective means of providing high quality care. Some facilities have implemented new service delivery models to help achieve this goal.

Some of the structural models being used by hospitals and other health care organizations are: Sigma Practice protocols and guidelines - The RCP works with the physician to develop the most appropriate treatment plan to meet a patient's respiratory care needs.

• Labor substitution - Some models for restructuring the delivery of respiratory services rely on shifting staff responsibilities.
• Decentralization of respiratory care departments - When respiratory care departments are decentralized, RCPs are assigned to specific nursing units and report directly to nursing supervisors.
• Patient-focused care - The principle of patient-focused care is to organize staff and services around the needs of the patient, bringing specific services and resources directly to the bedside to create a more "patient-friendly environment." Decentralization of respiratory care departments is often a feature of this model.
• Alternative employers - Large employers of RCPs have emerged in the long-term care and home care markets.

Value of Respiratory Care Practitioner Services

Many aspects of health system change encourage health care administrators to carefully evaluate the value-added by various types of personnel. In demonstrating their cost-effectiveness and contributions to high quality of care through the respiratory care literature, RCPs can help to secure their future positions in the changing health care environment.

The literature contains many examples of the cost-effectiveness of RCPs. Most of this literature demonstrates RCPs' cost-effectiveness in one of two ways:

• The use of protocols leads to cost savings.
• Increasing the responsibilities of RCPs can produce cost savings.

A variety of studies have also shown that for respiratory services RCPs provide quality of care that is equal to or better than care provided by other types of health care personnel. The published literature on this topic consists primarily of two types of studies demonstrating the quality of care provided by RCPs:

• Studies documenting high quality of care provided by RCPs through the use of protocols.
• Studies showing that RCPs have unique skills and expertise that contribute to high quality patient care.

While existing studies on RCP cost-effectiveness and their contributions to high levels of quality care offer initial positive results, more studies should be conducted to overcome some of these studies' limitations. Specifically, more studies should be conducted that rigorously examine outcomes, and particularly cost-effectiveness. Also, thus far most studies have been conducted in the hospital setting. As respiratory care is increasingly being provided in alternative practice settings, it would be useful to research RCP cost-effectiveness and quality of care in these settings, as well.

Conclusions from the Literature Review

The literature review examined the literature on respiratory care in the context of profound health system change, and its expression in the delivery of respiratory care services. The main message that emerges from this literature is that the dynamic market for respiratory care offers new challenges and new opportunities for respiratory care practitioners. Cross-cutting themes from the literature are summarized in Exhibit 3.

Exhibit 3: Cross-Cutting Themes
RCPs Must...	Examples	Take Home Message
Learn New Skills	Clinical Decision-Making Case Management Patient Education	Those RCPs who can demonstrate skills and the ability to take on responsibilities in multiple areas are likely to succeed in the new health care environment.
Adapt to New Practice Settings	Subacute Care Physician Offices Home Health Care Sleep Diagnostics	Marketplace demand for RCPs is shifting from the inpatient to both subacute and outpatient settings. RCPs can identify and take advantage of opportunities in these settings.
Commit to Improving RCP Education	Programs should include: Disease Management Reimbursement Criticial Thinking	RCPs must ensure that respiratory care programs teach future RCPs the skills they need in the new health care environment.
Learn About New Structural Models for Respiratory Care	Protocols and Guidelines Labor Substitution Patient-Focused Care	It is important for RCPs to understand the structural changes in respiratory care delivery systems. This knowledge will help RCPs work more effectively under these structures.
Demonstrate Cost-Effectiveness and Provision of High Quality Care	Therapist-Driven Protocols Increasing Responsibilities Specialized Skills	By demonstrating their cost-effectiveness and contributions to high quality of care through published work, RCPs can help secure their future.
Target Cost-Effectiveness and Quality Evidence to the Most Appropriate Audiences	Managed care trade publications for HMO executive audience Peer-reviewed medical journals for clinician audience	By targeting published evidence of their cost-effectiveness and provision of high quality care to the appropriate audiences, RCPs can build an excellent reputation among a wide range of potential employers.

AARC MEMBERSHIP SURVEY

The second component of the study, the survey of the AARC membership, supplements the qualitative and literature review research components with quantitative data from AARC members who work in varying positions and types of organizations in the respiratory care field. Survey participants included RCPs, clinical supervisors, and administrative supervisors working in one of the following three settings: 1) hospital, 2) long-term care (nursing home and subacute care), and 3) home health. The membership survey was conducted by telephone and over 471 AARC members completed the survey.

Data and Methods

The membership survey was designed to 1) assess RCPs' involvement in delivering high quality and cost-effective services to respiratory patients and 2) understand the changing demand for RCP skills. The survey covered a range of relevant areas (Exhibit 4). To develop the survey instrument, we relied heavily on background information obtained from both the literature review and informal interviews.

The survey sample was drawn from the AARC membership database. The sample included RCPs and both clinical and administrative supervisors of respiratory care, identified based on the job responsibility classification in the AARC membership database. The sample also included members working in one of three practice settings ­ hospital, long-term care, and home health, as designated in the membership database. All analyses were sample weighted to ensure that they are generalizable to the full AARC membership.

A range of statistical techniques were used to analyze the data. Sample weighted descriptive statistics were calculated (means, standard deviations, tabulations, and proportions) for all questions on the survey. Multivariate regression analyses were used to explore relationships between questions, and to compare responses to key questions among the major subgroups of respondents (position and setting).

Exhibit 4: Content of Surveys
Survey Section	Respondents
	RCPs	Clinical Supervisors	Administrative Supervisors
Practice Characteristics	X	X	X
Roles and Responsibilities of RCPs Skills and responsibilities Training Administrative Structure and Utilization of RCPs	X X X X	X X X X	X X X X
Cost-Effectiveness of Outcomes Generated by RCPs	X	X	X
Use and Sources of Guidelines for Respiratory Care	X	X	X
Administrative-Level Questions			X

Results and Discussion

The AARC membership survey represented an important opportunity to assess opinions about the roles and skills of RCPs and the impact of health market change on respiratory care practice from a cross-section of the respiratory care community. The survey results provide useful descriptive statistics on a variety of important topics, and highlight differences in perspectives among RCPs and supervisors in several different practice settings. Several important cross-cutting themes emerged.

1. The AARC membership believe that RCPs' strengths and value stem from their clinical skills and abilities.
   • Results from several survey questions strongly indicate that AARC members see RCPs as important and valuable for their abilities to treat, assess, understand, and manage respiratory illnesses.
   • When asked to rate the importance of various skills for RCPs, the most important skills were clinical knowledge, understanding and managing respiratory diseases, and using necessary tools (i.e., protocols) to treat patients. Clinical areas were also rated as being the most important areas for training. Finally, clinical skills were rated by administrative supervisors as the most important reason for employing RCPs.
   • More than 90 percent of AARC members viewed RCPs as being cost-effective for providing clinical services, even though they perceived RCPs to be less cost-effective for other services, such as case management.
2. RCPs need varying skills and play distinct roles in different types of practice settings. While RCPs in all settings are valued for their clinical skills, there is a diversity of needs, in terms of specific RCP skills, roles, and services, across practice settings.
   • AARC members' views on the relative cost-effectiveness of RCPs for performing specific tasks or providing specific services was also influenced by their practice setting, perhaps another indication of different RCP responsibilities within different settings.
   • Finally, while some practice settings are more likely than others to employ RCPs in specific positions (i.e., nursing homes and home health organizations are at least four times more likely than hospitals to use RCPs as case managers), results indicate that many employment opportunities exist for RCPs, both across the respiratory community and within individual organizations.
3. All types of health care organizations have restructured to less centralized models in recent years.
   • Sixty-seven percent of AARC members reported that their organizations have restructured within the past five years. Furthermore, restructuring has occurred across all practice settings in which RCPs work, not just in hospitals. Primarily, organizations have moved away from purely centralized models.
4. Other environmental changes have also created new challenges, and concurrently new opportunities, for RCPs.
   • Some of the challenges RCPs have encountered include increasing numbers of patients, as well as worsening casemix. Additionally, RCPs have been required to provide more complex services in recent years.
   • These same challenges can also be represented as opportunities for RCPs to apply their training and explore new career opportunities.
5. Although there is some pressure for RCPs to become more generalized, RCP clinical specialization is a key component of RCPs' value.
   • The majority of respondents have had to adjust to changes in the health care environment by either becoming more specialized or more generalized. Many RCPs (20 percent) have become more generalized, especially those working in the hospital setting, but a larger proportion (45 percent) have become more specialized.
   • Results suggest a tension between pressures encouraging RCPs to become more specialized and those encouraging increased generalization.
6. Managed care has influenced the nature of RCP duties.
   • RCPs have taken on responsibilities that are directly related to the emergence and growth of managed care as a major force in health care.
     • For instance, implementing guidelines has become a new duty for RCPs in the past five years; the survey results indicate that more than 98 percent of AARC members' organizations now use guidelines or protocols to deliver respiratory services.
   • Seventy-seven percent of members reported that RCPs have become responsible for managed care approaches to controlling costs. Additionally, administrative supervisors indicated that it is important for RCPs to understand reimbursement and cost containment strategies.
7. RCPs have only just begun to prove their value in managed care settings.
   • One indication that RCPs have begun to demonstrate their value under managed care is the degree to which respiratory disease management (DM) programs involve RCP services. Over 90 percent of the respondent organizations indicated RCP involvement in DM programs.
   • In other ways, however, results indicate that RCPs are not perceived to be as valuable in managed care roles. For example, 19 percent of AARC members believe that RCPs are not cost-effective for providing case management services.
8. There are significant differences in the roles of RCPs in traditional, acute care settings versus non-acute care settings.
   • Results from all parts of the survey indicate that acute care settings represent different challenges and opportunities for RCPs than do other settings, in terms of the structure of respiratory care service delivery, the skills required, the positions in which RCPs are employed, and changes in hiring of RCPs.
   • The skills required of RCPs differ in acute versus non-acute care settings; for instance, RCPs working in hospital settings may need higher levels of skills in respiratory care technology and pharmacology.
   • RCPs are also employed in different positions and have different responsibilities in traditional versus non-traditional settings. For example, RCPs in hospitals and subacute settings were at least three times more likely than RCPs working in other settings to become more generalized, and nursing homes and home health organizations are more likely than hospitals to use RCPs as case managers.
   • Finally, survey results indicate that job opportunities in acute care settings may be decreasing relative to non-acute care settings. For instance, those in hospitals were ten times more likely than those in other settings to report a decrease in the hiring of RCPs.
9. Outlook for the Future
   RCPs are facing new opportunities and challenges, from both traditional and increasingly important non-traditional practice settings. This membership survey successfully demonstrates the breadth of roles and responsibilities held by RCPs, and the value proposition that RCPs can put forward to respond to an increasingly diverse and dynamic health care marketplace.

STRUCTURED INTERVIEWS AND CASE STUDIES

As the final phase of this project, The Lewin Group conducted ten structured interviews of employers of respiratory providers, and two in-depth case studies of organizations employing innovative delivery systems for the provision of respiratory care services. The purpose of the interviews and case studies is to supplement the literature review and membership survey with perspectives from employers of respiratory care providers on desirable respiratory care skill sets and the relative advantages/disadvantages of RCPs versus alternative providers.

The interviews and case studies focused on employers of respiratory providers working for organizations representing new, managed care-related health delivery and financing models.

Interview Protocols

Interviews of employers and case study participants lasted approximately 30 minutes and were conducted by telephone. All interviews were conducted using a structured interview protocol. The initial protocol for employers of respiratory care providers was developed based on the literature review, the membership survey, and informal interviews conducted at the beginning of the study. For the case study interviews, we developed two modified versions of the initial protocol: one for participants at the case manager/staff therapist level, and one for managed care clients. The initial protocol developed for employers of respiratory care providers was used for case study participants at the employer or executive level.

Selection and Characteristics of Interview Subjects

Structured Interviews of Employers

Our goal was to select employers of respiratory providers in a range of managed care-related settings, including HMOs, home health, and long-term care. To broaden our perspective, we included both organizations that hire RCPs and those that do not. We interviewed a total of ten employers of respiratory care providers from a variety of settings, including three employers from home health/durable medical equipment settings, three employers from long-term care/skilled nursing facility settings, and four employers from health maintenance organizations/large group practice settings.

Case Studies

Our goal was to select case study sites that represent newly emerging respiratory service delivery structures. The two case study sites chosen to participate were a respiratory disease management company and a community hospital that runs a respiratory-therapist centered asthma management program. These organizations represent two very different, innovative delivery systems for respiratory care. Four case study participants plus one managed care client were interviewed from each site.

Results and Discussion

The interviews and case studies revealed important information about the respiratory care field and the changing roles of RCPs. While there are some limits to the analysis of purely qualitative information, it is important to note that interview methods such as these allow for collection of a very rich set of information by focusing in-depth on relevant issues. This information nicely complements the quantitative analysis from the membership surveys.

Exhibit 5 summarizes our key findings. The interviews with employers of respiratory providers suggest that RCPs are perceived as cost-effective and are valued by employers for the provision of specialized clinical services. However, many of the employers in managed care settings that we interviewed do not consider hiring RCPs in positions that do not relate directly to patient care, such as case management or administration. The interviews indicate that RCPs' greatest advantage in all settings, but particularly in managed care settings, is their specialized knowledge of respiratory diseases. For example, this level of disease-specific knowledge is extremely valuable for disease management programs.

Exhibit 5: Summary of Key Results from Structured Interviews and Case Studies
Content Area	Key Results of Structured Interviews and Case Studies
Delivery Structure of Respiratory Services	RCPs tend to be direct employees of home health organizations, hospitals, and disease management companies, but are contracted employees for managed care organizations and long-term care companies.
Utilization and Responsibilities of RCPs	RCPs are highly valued by all types of organizations for their clinical skills. RCPs hold a variety of positions and have many different responsibilities across organizations. While HMOs tend to only use RCPs for education and provision of clinical services, other types of organizations employ RCPs as administrators, case managers, and in other positions, as well.
Skills and Training	In addition to clinical skills, other important skills and areas for training for RCPs include: communication skills, patient assessment, case management, education, understanding of managed care and reimbursement, and knowledge of guidelines.
Cost-effectiveness of RCPs	RCPs are considered to be cost-effective for some services, such as those involving specialized clinical knowledge and education. However, Medicare reimbursement regulations limit the cost-effectiveness of RCPs in some settings (i.e., home health and long-term care). Several organizations have conducted studies documenting the cost-effectiveness of their RCP-centered programs.
Use of Guidelines	Guidelines for respiratory care are widely used by many types of health care organizations. When guidelines are not used, it is frequently because they are too focused on the acute care setting.

The case study results also suggest that RCPs' specialization, along with their ability to educate, are among their greatest strengths. The disease management company believes that RCPs' specialization and understanding of respiratory care is an asset for all aspects of the business, from providing clinical services to case management to marketing. Similarly, the hospital's outpatient asthma education program utilizes RCPs to run all aspects of the program, including grant preparation, provision of services, and reimbursement. Therefore, RCPs' responsibilities include an increasingly wide range of activities. RCPs have proven themselves in certain settings to be capable of adding new duties that do not necessarily directly relate to the provision of clinical services. It is likely that many people working in managed care organizations have not yet been exposed to the breadth of capabilities demonstrated by RCPs in other settings.

Our results provide strong evidence that employers highly value RCPs' abilities and find RCPs cost-effective for many activities and in a variety of settings. In addition to clinical skills, some of the skills that employers value in RCPs are knowledge of reimbursement and managed care, flexibility, interpersonal and communication skills, ability to educate, and knowledge of guidelines and clinical pathways.

The employers and case study participants that we interviewed offered a number of suggestions for ways that RCPs can increase their value, and particularly their visibility, in the current health care market. These results are summarized in Exhibit 6, below. While numerous suggestions were provided, everyone interviewed agreed that opportunities exist for RCPs in the evolving health care marketplace, and that RCPs as individuals and as a profession can help influence the future respiratory care market.

Synthesis and Study Conclusions

This final section of the Executive Summary synthesizes important cross-cutting findings from the three study components ­ the literature review, AARC membership survey, and structured interviews of respiratory care employers and case studies. The findings from each of the three study components, presented in the main body of this report, are highly detailed and represent a wide breadth of information. However, the results across all study components are consistent, cohesive and complementary, yielding a number of important insights and recommendations for the AARC. Our presentation of overarching conclusions from the study begins with a summary of key take-home messages. We conclude with a discussion of the broad implications of the study.

Key Take-Home Messages

1. Despite some pressure to generalize, particularly in acute care settings, RCPs are highly valued for specialized clinical skills.

All of the study components suggest that the highly specialized training and experience of RCPs are widely valued in the health care market. RCPs are perceived to be cost-effective for providing clinical services, and published studies indicate the cost-effectiveness of therapist-driven clinical protocols and increasing RCPs' clinical decision-making authority.

Furthermore, administrative supervisors indicated in our membership survey that RCPs' clinical skills are the most important reason why their organizations hire RCPs. Similarly, the respiratory employers interviewed indicated that they value RCPs for their specialized clinical knowledge. However, while specialized clinical skills are highly valued, there is evidence that RCPs are also being asked to expand their responsibilities beyond clinical, respiratory care services. In this sense, RCPs are becoming more generalized as they take on a broader range of duties and responsibilities. This phenomenon is particularly evident in the traditional hospital setting, where the roles of RCPs are evolving due to increased financial pressures and restructuring. Therefore, it is important that RCPs not lose sight of their core value in providing highly specialized clinical services, even as they take advantage of new opportunities.

2. While the importance of clinical skills is emphasized throughout the study, the study also demonstrates that other skills are an important ­ and necessary ­ supplement to a foundation of specialized clinical knowledge.

Exhibit 6: Employer and Case Study Participant Suggestions for the Respiratory Care Profession
Home Health/DME	Long-Term Care/SNF	HMO	Disease Management	Community Hospital
RCPs need to adopt expanded credentialing opportunities, for example, offering credentialing in areas such as case management that are available to other providers. There is a need to improve RCP education programs, including continuing education and credentialing. RCPs can use their existing clinical and education skills to launch careers in new practice settings. RCPs must get more involved in community and professional organizations. RCPs need to expand and utilize available clinical data demonstrating their cost-effectiveness.	There is a need for more research and lobbying at the national level to establish RCPs as a profession that is viable in the managed care market. Education programs need to focus on settings other than acute care. Reimbursement and policy issues need to be addressed, and RCPs must adapt their skills to deal with chronic, not just acute/episodic, illnesses.	RCPs need to understand the entire disease process and specialize in caring for diseases in different patient populations. RCPs need to market themselves as disease specialists not just equipment technicians. RCPs need to promote themselves as educators with specialized clinical knowledge. RCPs should also emphasize their ability to develop disease state management programs, not just to work in these programs.	RCPs need to emphasize their value for working in the home environment. The profession should also ensure that educational programs teach equipment and clinical skills for working in the home environment. RCPs should broaden their skills and demonstrate their value beyond traditional roles. RCPs should position themselves in the public view as patient advocates, and get involved in the federal and state legislative processes.	RCPs should learn as many skills as possible, and expand their work beyond the traditional scope of respiratory care. RCPs need to actively create opportunities, and not be afraid to take risks. RCPs should become involved in home health and primary care. RCPs need to demonstrate their value as educators. RCPs should move away from hospital-based care and align themselves with managed care organizations.

Study results suggest that there are a number of clinical and non-clinical skills that have particular importance in the current market, and these skills can be grouped in three categories: clinical, managed care/cost control, and communications (Exhibit 7).

Relative to traditional RCP skills, the skills emphasized in the study reflect the shift in RCP practice from treatment of an acute illness episode to increased emphasis on clinical and administrative decision-making. Clinical skills highlighted include patient assessment and case management, both of which require decision-making capabilities. Similarly, non-clinical skills, such as guidelines/protocols, communication, and flexibility were highlighted by both RCPs and RCP employers as particularly important.

3. Although there is substantial consistency across settings in terms of the importance of many skills, there is some variation among practice settings on desired skill sets.

The study helps highlight similarities and differences among practice settings in terms of RCP skills. Specialized clinical, disease management, patient assessment, and guidelines/protocol skills are important across all practice settings, reflecting the influence of similar factors across all types of practice settings.

However, study results also reveal that practice setting influences the relative importance of certain skills. For example, study results indicate that knowledge of pharmacology and medications and case management are more important skills in hospital and managed care/disease management settings than in subacute, long-term care, or home health settings.

Moreover, in terms of non-clinical skills, reimbursement/managed care environment skills are more important in long-term care and managed care settings than in home health, hospital, or subacute settings. Not surprisingly, education skills are most important in the managed care/disease management setting where patient education is an essential component of respiratory services.

Exhibit 7: Most Important RCP Skills
Clinical Skills	Managed Care/Cost Control Skills	Communication Skills
specialized clinical skills (i.e., knowledge of respiratory disease etiology) patient assessment disease management case management pharmacology/medication pulmonary function testing	guidelines/protocols reimbursement/managed care environment	flexibility oral communication/ interpersonal skills education/teaching

4. RCPs have begun to take advantage of emerging opportunities by entering new areas of clinical practice.

Respiratory care practitioners have adapted to changes in the health care environment by taking on new roles and responsibilities both in traditional and non-traditional settings. The literature on respiratory care indicates that the age of the "technician only" role of the RCP is long over. RCPs have become more involved in clinical decision-making, such as developing patient care treatment plans and conducting patient assessments. RCPs are taking on new duties including case management, design and evaluation of patient treatment plans, implementation of guidelines, and ensuring proper reimbursement procedures. RCPs are also finding opportunities as patient educators in a variety of settings.

The membership survey revealed that organizations of all types hire RCPs for multiple roles beyond the traditional staff therapist, including case manager, patient and staff educator, department head, administrator, and clinical supervisor. Interviews and case studies confirmed that RCPs are involved in a variety of new clinical delivery models in the respiratory field, including disease management and home health programs.

5. RCPs must adapt as jobs shift from acute care settings to other care settings.

There is evidence that increasing numbers of RCP jobs are shifting from the hospital setting to alternative sites of service, including subacute and long-term care settings, physician offices, home health facilities, and even sleep centers. Interview results with employers of respiratory care practitioners in alternative settings, such as nursing homes, suggest that demand for RCP services in these settings has grown during the last few years, and probably will continue to do so.

Different practice settings require different roles and skills, and even RCPs working in traditional settings must adapt to changes. While over 80 percent of the AARC membership work in the traditional hospital setting, their roles in these settings are also changing. For example, they are becoming involved in hospital-based disease management and patient education programs, helping implement guidelines and clinical protocols, and participating in case management activities.

Given these changes, RCP skills and training may be too focused on the acute care setting. Because hospitals, and specifically the treatment of acute episodes of illness, have been the center of RCP activity for so long, educational programs are geared toward preparing students for working in this setting only.

Under future, and in some places current, models of health care delivery, an inpatient educational focus may be inadequate. In addition to preparing students for clinical respiratory care-specific changes, educational programs must also prepare students for changes taking place across the health care system due to managed care. The importance of understanding areas such as disease management, cost-containment, and reimbursement is evident in all phases of our research.

6. RCPs are viewed as cost-effective for specific tasks and settings but additional studies must document overall RCP cost-effectiveness.

There is significant consensus across the study components that RCPs are cost-effective providers. However, the study also shows that perceptions of RCP cost-effectiveness vary based on the task, setting, and reimbursement structure in which RCPs practice.

For example, survey results indicate that RCPs are perceived as highly cost-effective for clinical services, particularly in the inpatient setting, and the interviews and case studies reinforce the survey results. Some studies, such as those highlighted in the literature review, have also been conducted providing further evidence of the cost-effectiveness of RCPs for provision of clinical services in the hospital setting.

However, while the published research is promising, there are relatively few scientific studies demonstrating RCP cost-effective-ness. Those that do exist are limited methodologically and are not broadly applicable to the full scope of respiratory care. Furthermore, few studies to date have evaluated RCP cost-effectiveness in alternative sites of service (e.g., nursing homes or home health), nor have studies evaluated the value of RCPs for undertaking new job responsibilities, such as case management. Therefore, despite some documented evidence of RCP cost-effectiveness, a larger scale effort needs to be undertaken by the respiratory community to fully examine these issues.

7. Reimbursement policy has important implications for perceptions of RCP value, particularly in long-term care and home health settings.

Medicare reimbursement policies impact the value of RCPs relative to other providers in both long-term care and home health settings. The literature demonstrates that use of RCPs in these settings is constrained by reimbursement restrictions. For example, home health companies do not receive additional payments for the patient education and training services offered by RCPs. As payments for home oxygen services are cut further, it will become even more difficult for home care companies to justify provision of these specialized services. Similarly, employers in long-term care settings indicated that reimbursement constraints limit the cost-effec-tiveness of utilizing RCPs more widely.

8. RCPs are increasingly performing "managed care duties," but their value in these roles is not well documented.

RCPs have become involved in implementing and performing managed care-related tasks. For instance, results from all of the study components indicate that a high percentage of organizations use respiratory care protocols or guidelines. Survey results also show that RCPs are involved in other managed care cost control techniques, including utilization review and case management, and organizations of all types are beginning to hire RCPs in managed-care related roles, such as case managers. Additionally, we found evidence in all phases of the study that RCPs have become involved in disease management programs.

However, there is little published literature documenting RCP cost-effectiveness for managed care duties. Furthermore, because managed care duties such as case management are new responsibilities for most RCPs, even anecdotal evidence of RCP effectiveness in these roles is limited. Additional research must focus on demonstrating RCP cost-effectiveness in managed care-related roles.

9. Some RCPs have demonstrated success under managed care models, but the profession must supply additional evidence to managed care organizations in order to succeed.

It is clear from the literature, the membership survey, and interviews and case studies that some RCPs are working successfully in managed care-related settings, including HMOs and disease management programs, as well as in other state-of-the-art delivery models. However, results indicate that perceptions do not always reflect these successes. For example, survey results show that administrative supervisors working in organizations with a high percentage of revenues from managed care are less likely to perceive RCPs as cost-effective for case management, implementation of guidelines, and cost containment. Furthermore, over twenty percent of AARC members do not believe that RCPs are cost-effective in managed care settings.

Interview and case study results highlight RCP successes working in managed care models. For example, several managed care executives found RCPs' clinical knowledge extremely valuable and found them to be cost-effective providers of educational, clin-ical, and disease management services. However, results also revealed that RCPs typically are not considered for case management and supervisory positions in managed care-related settings. Additional research demonstrating RCP cost-effective-ness in managed care settings, and increased visibility by the profession in these settings, is needed to help change these perceptions.

Implications for the Future

This study highlights the important changes in the health care market and their impact on RCPs' practice. While the evolving market poses challenges to the RCP profession, it also presents new opportunities. RCPs are beginning to take advantage of some of these opportunities both through new roles in the traditional hospital setting and in new delivery models in the home health, long-term care, and disease management arenas.

Despite dramatic changes in the health care system, RCPs' traditional core roles remain important. The study clearly demonstrates that RCPs are highly valued for, and are often hired because of, their specialized clinical skills. These highly valued clinical skills are not new skills for the profession, but rather have been defining skills of RCPs virtually since the beginning of the profession. Therefore, RCPs should not de-emphasize the core set of skills for which they are widely respected throughout the health care market. Instead, RCPs must build on existing strengths.

The study suggests that RCP successes in the market do not stem from wholesale change, but rather a broader application of existing skills. For example, some RCPs working in traditional, hospital settings have increased their value by taking on case management and cost control responsibilities. Similarly, other RCPs have successfully applied their knowledge of respiratory diseases to non-traditional settings, including disease management, home health, subacute, and long-term care.

The challenge for the profession is to translate these successes from individual accomplishments to profession-wide achievements that are recognized by the larger health care community. Efforts aimed at providing additional evidence of RCP cost-effectiveness as well as increased training in areas such as case management will help RCPs achieve this goal. Professional education must also evolve to keep up with the changing demands of the market. A final task is to closely monitor legislative changes impacting the profession, particularly in the areas of long-term care and home care services.

Dramatic changes in the health care system are forcing all health care providers to think strategically about their traditional roles and responsibilities. By leveraging existing skills, developing new skills, and actively demonstrating their value, RCPs can successfully position themselves as key players in the evolving respiratory care market.

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