a day in the life of a sleep educator… · a day in the life of a sleep educator by colleen...

A DAY IN THE LIFE OF A

sleep EDUCATOR

By

Colleen Bazzani RPSGT

colleen.bazzani@parknicollet.com

sleepeducat@charter.net

952-993-6008 1-800-945-0801

Sleep Educator

• Title and job description evolved over

many years

• Respiratory Therapy/Pulmonary Function/

Night/Day Sleep Technologist since 1982

• RPSGT in 1984

1990’s shadowed a Sleep Physician in the clinic to educate patient’s about OSA, sleep hygiene, and made arrangements for patients to be set up on PAP.

1990’s Community Service (Schools, Rotary, Lions Club, Community Education)

1997 Started the Park Nicollet CPAP Services (DME)

2000 Sleep Education Department

SLEEP EDUCATOR

10 Bed sleep lab

10 Physicians (pulmonary/sleep, masters therapist (CBT), dentist)

3 Sleep Educators

DME

NEEDED… liaison between the Sleep Lab, Sleep Clinic, and DME

The Sleep Educator as part of the Sleep

Care Team

PARK NICOLLET JOB

DESCRIPTION • A Clinical Sleep Educator communicates with patients,

families, and the community to educate individuals on sleep disorders, good sleep hygiene, ways to optimize treatment, methods to improve and monitor compliance with prescribed treatment, and in general assists patients in eliminating barriers to care in order to maximize their quality of life. The person in this position will work closely with the Sleep Disorders technical staff, Pulmonary/Sleep Clinic, the Health and Care staff, as well as other DME vendors.

Essential Tasks

• Schedule and perform download of PAP equipment

(Patient has already had one follow up with a Provider for Dx and treatment recommendations)

• Review information with the patient

• Determine pressure requirement/changes per established protocols.

• Process necessary paperwork.

• Communicate changes to the DME providers.

• Document changes in the medical record

Essential Tasks

• Work with the sleep lab staff/MD to process ordering of equipment following a sleep study.

• Review sleep charts for ordering details.

• Prepare Rx for physician’s signature.

• Assist with Medicare compliance and paperwork.

Essential Tasks • Carry and respond to the CPAP pager during clinic

hours.

• Assist with the morning PAP education as needed.

• Assist both in-patients and out-patients with mask fit, intolerance, and other compliance issues.

• Respond to patient’s calls to the “CPAP/Sleep hot-line” regarding problem or other treatment related questions.

• Assist DME providers with insurance authorization as needed.

Essential Tasks

• Participate in additional

patient education sessions.

• CPAP Education Class for

patients new to therapy;

held 2x monthly

• A.W.A.K.E. support group

meetings; held 3-4 times

per year

Essential Tasks

• Participate in presentations to educate and increase awareness about sleep and health, good sleep habits, drowsy driving, shift work/jet lag, and other sleep disorders.

• Staff a sleep display for corporate and school related functions.

• Assist Surgical Services with the sleep disorders evaluation for Pre-OP screening.

• Evaluate patient’s in the Bariatric Surgery Program

7:30 am - 9:00 am Sleep Lab

• Educate patient’s about OSA

diagnosis/treatment, DME selection,

Medicare rules, distribute educational packet

• Assist MD with Rx’s for patient to be set up

on PAP

• Download devices

9:00 am – 5:00 pm

• Download PAP devices and review with

patient (60 minute appt)

• Answer calls on CPAP/Sleep Information

Line

• Carry/answer pages to Clinic to assist with

pressure changes, mask fits, cleaning

information, and in- house hospital calls

BARIATRIC PROGRAM • All patients are screened prior to bariatric

surgery with a ResMed ApneaLink

• ApneaLink is scored and called results

• If positive=full sleep study

• If negative=proceed with bariatric surgery

• If already on PAP therapy a download is

required to document compliance

• Post-bariatric-ApneaLink study

CPAP/SLEEP HELP LINE

• Dedicated toll-free line for PAP questions sleep concerns, and reassurance

• Can minimize calls to the Sleep Lab, Clinic/MD office, and DME

• Calls should be returned in a timely manner to reduce patient frustration

• Helpful for traveling patients and snow birds

CASE STUDY

• 64 yo female, post- menopausal, new diagnosis of Atrial Fibrillation, wt. 210 lbs, BMI 32

• C/O insomnia, snoring, witnessed apneas, EDS, drowsy driving

• Sleeps 7-8 hours has HTN

• Occupation: School bus driver

Question #1

After reviewing the patients case study

information. What comorbidity related to

OSA should be recognized with this patient?

A. Diabetes Mellitus

B. Congestive Heart Failure

C. Ischemic Heart Disease

D. Atrial Fibrillation

Answer to Question #1

After reviewing the patients case study

information. What comorbidity related to

OSA should be recognized with this patient?

A. Diabetes Mellitus

B. Congestive Heart Failure

C. Ischemic Heart Disease

D. Atrial Fibrillation (this is the only comorbidity that the patient

has based on her case study)

SLEEP STUDY

• Sleep study: AHI 44/hour, RDI 75/hour, REM AHI 60/hour, Low Sa02 71%, ESS 12

• Titrated to 8 cmH20, no REM Supine sleep

• Set up on AutoPAP 5-15 cmH20, nasal mask, heated humidity

Question #2

Based on the case study/sleep study results,

what important finding should be discussed

with this patient?

A. Mild OSA

B. Cheyne-Stokes Respirations

C. Severe OSA

D. COPD

Answer to Question #2

Based on the case study/sleep study results,

what important finding should be discussed

with this patient?

A. Mild OSA

B. Cheyne-Stokes Respirations

C. Severe OSA (AASM, 2nd Edition, defines severe

OSA as an AHI of 30>/hour)

D. COPD

How is everything going with the

PAP machine?

• Ugh! I hate this thing and I am still tired. It

takes me 1 hour to fall asleep and I am only wearing it 4-5 hours. I am readjusting the mask most of the night. I feel like I am waking up every 1-2 hours. It wakes me up blowing too hard and I take it off at 4 AM and go back to sleep with out it.

Download Reveals

• 20 out of 35 nights of usage for 5 hrs/night

• Leak at 58 L/minute 95% of time (leaking

is every 2 hours and worse towards end of

night)

• 95th percentile pressure is 10 cmH20

• AHI at 4.5/hour

Discuss with Patient

• Congratulations!

(5.5 hrs is good for the first month, it usually takes people 1-2 months to get acclimated)

Next: Review Sleep Study… AHI and grading scale, consequences of untreated sleep apnea and benefits. Correlation of A-Fib and OSA. Goals for the download AHI

Discuss with Patient

• Review download AHI 4.5/hour…give positive feed back

• Address mask leak threshold and goals

Likely REM related…Give WHY!...mouth is dropping open, paralyzed, REM AHI

• Solutions: chinstrap, full face mask, Cover Roll Tape

• Review mask fit and humidity concerns

• Discuss weight loss benefits and pressure changes that might occur.

Question #3

Based on the case study/sleep

study/download…What sleep related issues

could be addressed with this patient?

A. Sleep Hygiene/Insomnia (this patient does

not have the other sleep related issues)

B. Sleep Enuresis

C. REM Behavior Disorder

D. Sundowning

Answer to Question #3

Based on the case study/sleep

study/download…What sleep related issues

could be addressed with this patient?

A. Sleep Hygiene/Insomnia (this patient does

not have the other sleep related issues)

B. Sleep Enuresis

C. REM Behavior Disorder

D. Sundowning

Patient admits she does feel a little

better, but not perfect. Napping on the

weekend.

• Address: Insomnia and Sleep hygiene

• Desensitize techniques before bed

(wear PAP while reading/watching TV)

• Congratulate about 5.5 hours of PAP

usage, but 7-8 hours will make you feel

more rested.

• (PAP is like a medication…)

SLEEP HYGIENE

• Wear during naps and with all sleep

• Explain about REM cycles occur every 1.5

hours and it is normal to awaken briefly,

but just now more aware due to PAP.

They will likely lessen in 1-2 months.

• Address drowsy driving risks

AFTER VISIT SUMMARY

• Write down Sleep/PAP recommendations for

patient. Give related pamphlets to patient.

• Discuss follow up with Sleep MD for DOT

(paperwork to be completed by MD only.)

• Remind patient follow up in cardiology for A-Fib

• Remind: Follow up with EDS, or return of other

symptoms, weight gain/loss, drowsy driving

Example of Dictation • Jane Doe came to the Sleep Disorder Center on 8-14-13, to download and review the data from her PAP

equipment. She has been diagnosed with obstructive sleep apnea. The sleep study date was 5-4-2009 and the

results were reviewed with the patient. The AHI (Apnea Hypopnea Index) was 44/hour, RDI (Respiratory

Disturbance Index) 75/hour, Low Sa02 71%. She is on an APAP settings of 5-15 cmH20 set up by Park Nicollet.

The patient has worn the equipment for 20 out of 35 nights. Average usage has been 5.5 hours per night. She

was congratulated on her success thus far. Mask leak is large at 58 L/minute. She appears to be opening her

mouth and the leaking looks REM related.

The AHI (Apnea Hypopnea Index) while on PAP has been good at 4.5/hour and the 95th percentile pressure is 10

cmH20. The patient reports feeling better, but not quite fully rested. Risks of untreated sleep apnea and the health

benefits of PAP therapy were reviewed. Mask fit educational information was reviewed wit the patient. Patient was

instructed to contact the PAP information line if problems or concerns arise.

Recommendations: Extend sleep on PAP therapy. The patient has decided to try a chinstrap with her

mask. She is aware she may need a full face mask. She will re-download in 4-6 weeks. She will follow up

with the DOT physician to discuss driving clearance. She is aware that she should not drive while

drowsy. Sleep hygiene tips were reviewed. Medicare rules were reviewed as she will be retiring soon.

Patient will follow up with Dr. Lisa Bolin annually.

The supervising physician is Dr. Sue Ravenscraft.

Face to face time spent with the patient was 45 minutes.

Motivational Interviewing

Introduced in 1980’s.

Used by health professionals in the

management of chronic illness when the

patient is asked to change their lifestyle

habits.

Motivational

Interviewing Principles

1. Express empathy by understanding the

patient’s concerns

2. Identify differences in the patient’s behavior

and focus on positive reason for changing.

3. Expect and adapt to resistance to change

4. Support patient self-efficacy

SLEEP EDUCATORS …

• Explain the importance of diagnosis and the reason for the treatment. THE WHY!

• Identify potential problems and set backs to treatment

• Tips for increasing compliance regardless of the PAP device to patient and family

• Tips for sleep extension on PAP and sleep hygiene

SLEEP EDUCATORS …

• Communicate effectively…be positive and encouraging!

• Use Motivational Interviewing techniques, Teach-Back Method, and Demonstration/Return-Demonstration.

• Know your audience and have the ability to recognize and be sensitive to patient cues. Then be able to respond accurately and provide support and feedback.

• Skills that promote a sense of trust

• Be sensitive to family, religious beliefs, language, and cultural values

• Determine learning needs

• Be non-judge mental about a patient/bed partners intrusion to the bed time routine, sleeping habits, and bedroom set up

SLEEP EDUCATORS …

• Reinforce cleaning procedures and provide written material

• Review changing the humidity settings (Return-Demonstration Method).

• Be familiar or have resources… of all manufacturers and modes of PAP therapy.

• Address concerns and offer suggestions to bed partners.

• Offer personal empowerment to patient…always praise them!

• Provide information on travel, surgery, and hospitalizations

IMPORTANT INFORMATION

• Patient appointment visit must be

physically in Sleep Lab space (not in the

clinic or DME)

• Need a physician on site for billing and

the MD needs to be available for

consultation about our patients (we use

our hospital/ICU Sleep/Pulmonary MD)

Billing

• NEW…Need an order signed by a Sleep

provider (valid for 1 year)

□Sleep Educator to download data, assess,

and treat.

The 2014 Hospital Outpatient Prospective

Payment System (OPPS) rule replaced the

5 Levels of Visits (99211-99215) into one.

G0463 Evaluation and Management Codes

(Facilities Code)

We can bill using this code as long as

data is reviewed with the patient and

there is an order

CMS

(Centers for Medicare and Medicaid

Services)

CMS replaced the CPT codes with a single

Healthcare Common Procedure Coding

System (HCPCS) code describing all clinic

visits, G0463, Hospital outpatient clinic visit

for assessment and management of a

patient.

CMS

National payment rate of $92.53

National copayment of $37.01

SLEEP EDUCATORS

SHOULD…

Be a resource for the sleep physicians

and nurse practitioners

• Know the Medicare rules/guidelines for

compliance.

• Know the indications/contraindications for

advanced PAP therapy.

• “Know” the qualifying rules for RAD

devices.

Park Nicollet Medicare

Patients

• Visit with CSE at day 30 for a download and

education.

• Visit with MD at day 60 for a download/ face to

face for compliance check (Compliance

verification can only be done by provider). If

compliant…F/U one year.

• If not compliant…back to CSE for assistance

then back to MD before day 90.

RESOURCES

Fundamentals of Sleep Technology

Enhancing Therapeutic Compliance, First Edition, Chapter 47, by Colleen Bazzani, RPSGT

Patient and Family Education, Second Edition, Chapter 56, by Melinda Trimble, LRCP, RPSGT and Rose Ann Zumstein, RPSGT

Lippincott, Williams and Wilkins, 2007 and 2012

www.motivationalinterview.org

[Sleep is] the golden chain that ties health and our

bodies together Thomas Dekker- English dramatist (1572-1632)

Mackinaw City Michigan