Taking Advanced Respiratory Patients on Hospice


Are we being asked to do too much?  Should we do it? 

This article does not attempt to answer those questions; as the answers differ for every hospice – a philosophical decision made within your organization.  This article aims to inform, educate, and provoke thought on the increasing demand for advance respiratory patient care. 

A goal for every hospital is to reduce readmissions.  Specifically, to keep the patients from returning within 30 days post discharge.  The pressure to reduce readmissions coupled with the alleviation of Medicare regulations on the use of advanced respiratory products as part of the continuum of care are driving the growing trend of sending patients home with advanced respiratory support.  According to J. Diaz of Anchor Enterprise, a noted pioneer in advanced respiratory support in the hospice setting, “With home health or no assistance, we see patients often being sent home with very little support.  If any, just a BiPAP and antibiotics.  These patients may be stable at home for five to seven days but often return to the hospital.  Hospitals are becoming very aware of these re-admissions.  As a result, hospices are increasingly in the mix, so the level of care and medical expertise are commensurate to the patients’ needs.”  This means hospices need to be forewarned and forearmed.   

Hospice in general is getting more comfortable with these patients.  Manufacturers do a better job marketing, and facilities that once refused the patients now admit them.   Demographics also play a role as COPD is being diagnosed in a younger generation. 

Are advanced respiratory devices palliative or curative?  How might this impact reimbursements?  Is the benefit of hospice increasingly being asked to do too much?  What should we do now?

The Framework:

Advanced respiratory patients are usually diagnosed with COPD, Lung Cancer, ALS, Pulmonary Fibrosis, Bronchiectasis, Muscular Dystrophy, or Muscular Sclerosis; or a patient who had a Tracheotomy.   Such patients are usually given one or more of the following products to reduce anxiety and breathe easier:  Ventilator, BiPAP (S, ST, AVAP), and AIRVO.

Ventilators are portable and flexible tools used to bridge the gap between the hospital and home care.  The most popular option is the Trilogy Ventilator.  The Trilogy device provides volume-control and pressure-control for invasive and non-invasive ventilation and has a four-hour battery life with additional AVAP, ST, CPAP, and SIMV modes.  The most popular use for the Trilogy ventilator is the AVAP mode.  AVAP mode can automatically adjust to support a patient’s need without exceeding set pressures and volume.  The Trilogy device has set parameters that prevent more harm to the lungs, including barotrauma and air trapping. 

The AIRVO system features a humidifier with integrated flow source that delivers high flows of air/oxygen mixtures to spontaneously breathing patients, through a variety of interfaces up to 60 L/min.  Restrictive lung disease and trach patients benefit the most from this device.  Patients with restrictive lung disease require a gentle distribution of air to support air hunger, shortness of breath, and to decrease work of breathing.


The Conundrum:

Although Trilogy Ventilators and AIRVO machines will likely triple the DME cost for a patient, there may be benefits to taking on these unique cases.  Hospices with a defined advanced respiratory program often experience census growth.  Their census increases because they admit patients that may be turned away elsewhere; and those patients live longer than similar patients without their needed advanced respiratory equipment support.  These hospices help patients and caregivers cope with the painful effects of terminal illness. 

The big question is the net impact of such patients to the attending hospice’s bottom line.  With enhanced DME costs may come less need for Rx, medical supplies, and active nurse support to these patients.  Can patients with advanced respiratory needs be treated profitably?


To Do or Not to Do:

Though gaining in popularity, only a small percent of hospices have made the decision to actively admit and support advanced respiratory patients.  Most other hospices either refuse or resign themselves to admit enough to keep referral sources happy.  

Here are four things to consider prior to admitting an advanced respiratory patient:

1)    Local support:  Understand it is a team effort.  To take on an advanced respiratory patient, you essentially create an advanced respiratory program within your hospice; even if it is just for one patient!  This program team may consist of doctors, pulmonologists, respiratory therapists, clinical nursing support, and the DME provider.  None of this is possible without a DME provider who understands and provides advanced respiratory products.  Ventilators and AIRVO machines are a steep investment both financially and logistically for DME providers.    These devices require specific training and access to 24/7 RT support.  Your contracted DME providers and other local providers may not have access to the equipment or support needed, and it is not uncommon for a DME provider to have the equipment, but then lack the RT support.  In this case, you would need to contract externally for the RT support and ensure they are available 24/7.  There are ventilator leasing programs available in the industry, if you find your current DME provider unwilling or unable to take on the investment in advanced respiratory equipment.


2)    Education: It is important to align your organization with a DME provider who understands the specific demands of advanced respiratory patients and who is willing to help educate your team.  Your DME provider and clinical staff are direct extensions of your hospice, and neither the patient nor caregiver differentiate between the two.  The specific training required does not stop with the DME provider; your clinical team needs similar training. Your clinical team needs to instill confidence in the family by having a comprehensive understanding of how these devices work, and how they affect patients.


3)    Individualized Plan:  The plan of care needs to be customized to meet the needs of each patient.  This starts with the doctor, pulmonologist, and/or RT consultations and continued with your local support system.  The advanced respiratory program team works together to present a plan that manages the systems of your advanced respiratory patient. 


4)    Alternative Options:  You may not be able to serve a patient who has some of these advanced respiratory products.  This is not only a clinical decision, but a financial and philosophical one as well.   Or you may find yourself with no local support and no other options.  This goes back to the individualized plan and discussions with your advanced respiratory program team . . . Do alternatives exist for this patient?  For example:  A Trilogy Ventilator has multiple BiPAP settings.  It is not uncommon to see a patient using a Trilogy Ventilator in the hospital then discharge home and use the Trilogy Ventilator on BiPAP settings.  Not only do you incur an expense three-times the rate of a using normal BiPAP, you risk losing a patient that you could help if your DME provider does not have a Trilogy Ventilator.  A BiPAP in this case is a much more common item carried by most DME providers nationally.

The below table shows what goes into serving an advanced respiratory patient:

*Table and recommended service descriptions provided by Anchor Enterprise.  It is a general guideline to assist in understanding various diagnosis and related services, but in no way is an endorsement or recommendation of treatment by Anchor Enterprises, Qualis Management, or SONO.

Screen Shot 2019-07-24 at 11.12.52 AM.png

The trends driving advanced respiratory needs will continue to expand, and so advanced respiratory support will continue to gain popularity in the hospice industry.  Trilogy and AIRVO marketing are also expected to expand, which will increase consumer awareness that these programs and products might be available.  As a result, the hospice industry will start seeing facilities, referral sources, and the patients themselves asking for these products.     

What to do?  If you think providing advanced respiratory devices to patients is being asked to do too much, you can simply refuse.  However, if you decide to get ahead of the curve by researching everything that goes into serving these patients or clinical support alternatives, we can help you research.   

If you are interested in learning more about advanced respiratory equipment, advanced respiratory programs, or equipment leasing structures, please contact Jared Kelley at


(Note:  Qualis has no direct or indirect investment in any DME device, program, or methodology.  We simply serve hospices with professional DME management and gladly share what we know with the hospice industry.  It will be most helpful if you share with us what works effectively with your hospice, as well as what challenges you face.  We welcome opportunities to learn together and assist hospice leaders provide excellent patient care while honoring their fiduciary responsibilities).

by: Jared Kelley

SVP, Special Projects at Qualis Management