Discharge and community planning

A person with spinal cord injury (SCI) who has respiratory dysfunction beyond the sub-acute phase of management, will have ongoing ventilation and respiratory health needs for community living. Community planning—either during hospital discharge processes or through community-based reviews—is essential to reduce the risk of hospital readmissions for respiratory complications, but also to improve quality of life and participation. This community planning is necessary to secure adequate funding, personal care and health professional supports, as well as facilitate the trialling and prescription of necessary ventilation and respiratory devices.

Documentation

Documentation of key ventilation support and respiratory health needs and management recommendations can support advocacy, liaison and referrals, while highlighting resources required for implementation. This documentation can express planning on a number of levels such as a ventilation management plan, respiratory health plan, respiratory care plan and respiratory device plan.

Funding advocacy and liaison

To implement the recommended ventilation support and respiratory health plans, funding may be required for specialised devices, additional care support, and timely access to healthcare professionals. Securing adequate funding will require knowledge of relevant funding schemes.

Some devices—such as a continuous positive airway pressure (CPAP) device—may be available on long term loan via a government health scheme (e.g. Queensland Health Sleep Disorders program) if eligibility criteria are met. Other devices may be cost prohibitive, so government aged care, disability or insurer funding schemes may enable access.

Securing adequate funding will also require compliance to specific funding guidelines, along with targeted advocacy and liaison. Provision of ventilation support, respiratory health and respiratory care plans will significantly aid advocacy and liaison processes, by providing justification.

At the same time, all funding schemes require a comprehensive rationale that clearly demonstrates the request is not only clinically indicated, but also reasonable and necessary. This means it must be related to the person’s aged care and/or disability need, support their functional needs and goals, while representing value for money.

Care support recruitment and training

Once adequate funding has been secured, care and nursing agency recruitment or review can proceed. It is essential to ensure respiratory care needs are clearly communicated and can actually be met, before service agreements are formalised or renewed.

Key steps in this process include:

• supplying the ventilation support, respiratory health and respiratory care plans to the care and nursing agency to inform the selection process and service agreement
• clarifying agency policies and practices which may impact service provision capacity, timeline and costs (e.g. care vs nursing job descriptions, skillset of existing care staff, number of new staff needed to recruit to care team, active vs inactive overnight shift requirements, minimum call-out pricing, staffing ratio requirements for tasks, training needs for competencies)
• negotiating solutions to identified service provision or capacity gaps (e.g. offering additional training and resources to upskill care team, commencing care shifts in hospital prior to discharge, brokering services)
• facilitating the recruitment and rostering of an appropriately sized care team, along with support to develop the necessary care skills and rapport building.

Health support referrals

Ongoing respiratory health support may involve a combination of public services (e.g. hospital outpatient clinics and bulk-billing GP) and private community providers (e.g. nursing, physiotherapy, speech therapy and dietician). Referrals should be finalised prior to hospital discharge.

Key considerations in this process include:

• consulting with the respiratory physician to clarify ongoing public or private follow-up links
• completing referral to the GP and supplying medical discharge summary and plan documentation to:
  • update a Chronic Disease Management plan
  • finalise a respiratory action plan (e.g. scripting of antibiotics, pathology samples)
• completing referrals to public and private health professionals and supplying relevant discharge summaries and plan documentation to:
  • clarify role in assisting the implementation of the ventilation support or respiratory health plan
  • support outstanding care agency training needs
  • establish frequency of initial services
  • provide care coordinator and other multidisciplinary contacts
• liaising with the funding coordinators to confirm care agency and health professional service agreements are in place for future appointments
• liaising with the care agency coordinator to confirm rostering and transport needs are arranged for future health professional appointments.

Trialling and scripting respiratory devices

Trialling and scripting of ventilation devices will typically occur during hospital admission or via sleep-disorder clinics, under the guidance of a respiratory physician. Trialling and scripting of respiratory devices will normally be completed by physiotherapy and nursing and this is discussed below.

Wherever possible, low-cost respiratory devices and simple respiratory health strategies should be trialled first, before progressing to more high-cost devices and complex practices. Documentation of trial outcomes of low-cost respiratory devices which are deemed inadequate, will support funding submissions for high-cost respiratory devices as reasonable and necessary.

Some low-cost devices may be readily available to order via online suppliers and are likely to be satisfactory (e.g. peak flow meters). Other low-cost devices may require more careful selection, yet not be available for trial. For example, portable suction units intended for home-use can differ significantly from hospital-grade models: their suction pressure and flow rate, as well as capacity for high frequency and sustained usage can be quite different—factors that directly affect sputum clearance and therefore the risk of respiratory complications and potential hospital readmission. Hence, supplier guidance and product feedback is essential to guide prescription.

Mid to high-cost respiratory devices must be adequately trialled prior to submission for funding to confirm clinical suitability. Developing relationships with suppliers can greatly support access to trial devices or hire arrangements, improving product selection, user engagement and funding approval success.

Specifically, mechanical insufflation-exsufflation (MI-E) devices—commonly referred to as “cough assist machines”—are a high-cost respiratory device, used for providing the physiotherapy techniques of lung volume augmentation and secretion management. In recent years, some older models have been discontinued, leaving no supplier support for servicing and limited access to replacement parts. At the same time, new devices are entering the market and clinical feedback is gradually emerging. The trialling process is described in more detail below. If required, professional networks and specialist services should also be approached to request support. A list of current MI-E devices and suppliers is also provided, and the capacity to trial versus hire and purchase may also be explored.