Positive Reinforcement

[lyankowy]

Are there any PAP users out there who receive positive reinforcement communications from their DME companies after you've been compliant? For example, do you get an email after your SD card is read saying, "Congratulations! You're compliant!" or something like that...

[jdr999]

I think "compliant" and "treated" are two different things altogether.

Being compliant with a treatment plan that isn't working should be of no value to you. I'd be much more interested hearing "Congratulations! Your monthly AHI is now down to only 1.7!! Keep up the great work!"

Compliance is *required* for insurance billing. So generally the only one who is helped by compliance data is the DME (since they can then bill for another months rental).

I'm all for positive reinforcement though -- a positive support team can make all the difference in the world!

[CapnLoki]

Are there any PAP users out there who receive positive reinforcement communications from their DME companies after you've been compliant? For example, do you get an email after your SD card is read saying, "Congratulations! You're compliant!" or something like that...

Sort of - they called to say that because I was compliant I could now order more supplies. I'm sure their motives were purely altruistic.

[lyankowy]

I'd be much more interested hearing "Congratulations! Your monthly AHI is now down to only 1.7!! Keep up the great work!"

Thanks for the reply! This is great help. I work in a clinic and am starting a PAP Compliance and Success Program and am looking for ways to help PAP users with their adherence. I like the specifics of mentioning their AHI. Great insight!

[CapnLoki]

Compliance is *required* for insurance billing. So generally the only one who is helped by compliance data is the DME (since they can then bill for another months rental).

I'm not sure I'd go that far - since non-compliance is the single biggest problem with pap therapy, anything that improves that is a plus. So the question to ask is, how many people became compliant when their DME reminded them they will lose the coverage (owe money, have to return hardware, etc) if they don't comply.

Also, I'm curious how much of the hardware we see on the grey market comes from non-compliance. Its nice to see masks on EBay for 25% of list, but is that actually funded by insurance/Medicare with scammers pocketing the cash?

[jdr999]

I'm not sure I'd go that far - since non-compliance is the single biggest problem with pap therapy, anything that improves that is a plus.

True, we all have to start somewhere. If you have a treatment plan for patients with particular goals in mind, then compliance could certainly be the first goal. But that reinforcement email should be based upon current goals - hopefully leading to more than just basic complaince.

[Janknitz]

I think the masks we see on auction sites and the like for 25% of retail are pure theft--by our DMEs.

Manufacturers supply free samples, intending them to be used by DMES for fitting and trial purposes. Instead, DMEs sell them out the back door. You can bet when a vendor has a large supply of new, sealed masks, that's where they are coming from. Meanwhile, newbies often cannot get a decent mask fitting and trial period, because its too much trouble for the DME's. and the retail costs of masks is high because manufacturers have to recoup the cost of these sample masks somewhere. A viscious cycle.

[chunkyfrog]

. . . I work in a clinic and am starting a PAP Compliance and Success Program and am looking for ways to help PAP users with their adherence. I like the specifics of mentioning their AHI. Great insight!

Comfort cannot ever be underestimated as a factor in successful cpap use.
AHI is not available on all machines--(but it really SHOULD be; maybe even more so--leak rate.)
With an eye to comfort, mask fittings should be done lying down and under that patient's therapy pressure.
Mask exchanges should occur until the patient is satisfied with fit and leakage is low enough for proper therapy.
Comfort accessories should be accessible--mask liners and strap cushions, like Pad-a-Cheek, or Rem-zzz's.
Provide samples if possible. Encouragement is not much use to someone when they are distracted by a blistered nose.

[Janknitz]

I agree 1000% with Chunky. Mask comfort first and foremost. Secondly, involve your patients in their care by empowering them to check their own data and use the information to optimize treatment (even if you are uncomfortable with patients tweaking settings, you can teach patients when to collaborate WITH you to optimize treatment and to problem-solve).

The corollary here is you must INSIST that patients receive fully EFFICACY data capable machines. No bricks!

[lyankowy]

The corollary here is you must INSIST that patients receive fully EFFICACY data capable machines. No bricks!

I agree. For the most part, the DME companies I work with are now only providing machines which record the essentials.

[robysue]

I'd be much more interested hearing "Congratulations! Your monthly AHI is now down to only 1.7!! Keep up the great work!"

Thanks for the reply! This is great help. I work in a clinic and am starting a PAP Compliance and Success Program and am looking for ways to help PAP users with their adherence. I like the specifics of mentioning their AHI. Great insight!

Positive reinforcement is a good idea, but----

1) Focus on SUCCESS first. Compliance is a necessary requirement for successful CPAP therapy, but compliance is NOT sufficient to guarantee successful CPAP therapy.

2) Make sure that all patients/clients are prescribed machines that record full efficacy data. That will allow you to give useful positive feedback to PAPers who are compliant, have low monthly AHIs, and have monthly leak rates that are acceptably low. In other words, it's worth throwing in a congrats to PAPers whose monthly 95% or 90% leak rates indicate that they are having no problems with leaking as well as congrats to PAPers who are compliant (in terms of machine usage) and PAPers with low monthly AHIs.

3) Offer meaningful help to the clients who are NOT compliant or whose monthly AHI remains too high or who clearly have leak problems going on because of the monthly 95% or 90% leak rates. If your clinic would get into the habit of downloading all the detailed data and looking at the leak data for the last week of the monthly data, that would provide even better insight into figuring out which patients may have leak problems. Make sure the wording of the letter, email, or phone script that you use to contact the clients who are obviously in trouble does not inadvertently put the blame on them. Something like, "We've noticed your leak rate is higher than it should be. What can we do to help you find and fix the leaks?" is much better than "You are mouth breathing and we think you need to try a chin strap." For clients whose monthly AHI remains too high, you need to encourage them to contact their sleep doc and you need to be specific about why you are making that suggestion. Something along the lines of "Your monthly AHI = *** indicates that your CPAP machine is not optimally treating your OSA yet. We encourage you to contact your sleep doctor's office and share the enclosed data with him/her so that he/she can make an informed decision about any necessary changes to your CPAP therapy."

4) For clients who simply are not using the machine enough of the time, try to take the sting out of the "noncompliance" letter---the client already knows how much (or rather how little) they're using the machine. So offer a real olive branch when contacting these folks. Instead of "You are not using the machine enough to be compliant with your insurance companies requirements and if compliance is not improved by <insert date>, the insurance company will no longer pay for your supplies and you will be required to return the machine to us," try something like: "Your usage numbers show that you are having real problems using the machine all night long every night. We want to offer our help in sorting out what kinds of problems you are having that are preventing you from using the machine all night long. We know that the adjustment period to CPAP therapy can be difficult, but we want you to know that there are solutions to the problems you are running into. Please contact our office and set up an appointment with a CPAP-mentor so that we can learn what your problems are and so that you can learn strategies for dealing with those problems."

6) Find a way of really listening to every client who is struggling with therapy. Not everybody who struggles is non-compliant in terms of usage, but the harder the adjustment period, the more likely the client will eventually just give up. All too often people who are going through serious adjustment problems are given too little useful information. If you make a recommendation, explain why you're making the recommendation and as much as possible, and base that recommendation on both the data from the machine and what you are hearing the patient say to you. It does not help to tell a struggling patient to "use a chinstrap" when the leak data makes it clear that they have no problem with mouth breathing issues or leaks in general for example.

7) (This one may be hard to do.) See if you can get some kind of "mentor/mentoree" program going at least for the folks in trouble. Perhaps some of your successful "alumni" would be willing to mentor newbie PAPers in trouble. The thing that I wanted more than anything during my long 6-8 month difficult adjustment period was the chance to talk to another PAPer who had had trouble adjusting but had managed to figure out a way to make it work. Talking with a PAPer---NOT an RT, PA, sleep doc---was what I craved for months and months. And all of the multiple trips to the doc's office to talk to the PA who did NOT use a machine and the DME to talk to the RT who did NOT use a machine often left me even more frustrated and angry about the whole mess I found myself dealing with alone in my bed each night. If I hadn't found this forum, I doubt that I would have made it. But nonetheless, I craved face-to-face contact with another PAPer who had real troubles adjusting during my first very difficult year of PAPing.

[chunkyfrog]

Robysue: +100
For health's sake, the therapy must not hurt, and the patient has to feel better because of it.
"Attaboy's" and pats on the back may be easier to administer, but true involvement will go much farther.
Asking questions requiring more than a yes or no answer, and then listening will gain far more mileage.
And your patients will be around much longer.