5 Questions to Consider Before Launching Your New Hospital-Based Wound Care Program

Hospital-based outpatient wound care programs have experienced explosive growth in a relatively short period of time, despite being relatively “new” to the healthcare industry. An aging population has brought significant health concerns among older patients, including type 2 diabetes, venous insufficiency, obesity, increasingly sedentary lifestyles, tobacco use, and other comorbidities that are taxing our healthcare system. Care of chronic wounds provides a cost-effective solution for this patient demographic, with a primary goal of amputation prevention and a secondary benefit of reduced hospital admissions and/or readmissions seen as motivation. The wound care product industry has also driven outpatient care and is expected to grow to $22 billion in the United States by 2022.¹ The product industry has largely driven advancements in the field of wound care research while increasing awareness about wound management. Currently, there are approximately 1,500 wound care centers nationwide, based on conservative estimates collected during the authors’ research for this article, with many more hospitals considering adding a wound care program to their outpatient service lines. There’s no question that wound care programs offer a viable solution for hospitals; however, opening and operating an outpatient wound care program is not easily accomplished. It’s a unique service line that takes committed leadership, upfront capital, and a clinical staff that deeply believes in the service line to make it operate successfully and provide long-term value to the community.

Is your hospital ready for an outpatient wound care program? This article will help those organizations considering the addition of a wound care program answer that question by addressing key considerations. Readers are encouraged to use the following five questions as a guide to determine whether adding a wound care service line to one’s hospital seems logical and sustainable.

Question 1: Does the idea of an outpatient wound care program solve specific problems for your hospital?

The shared motivation that the authors see as a primary driving force behind every hospital that is considering an outpatient wound care program is a deep level of concern for its existing patient population living with untreated chronic wounds. Beyond compassion, however, there is usually a secondary reason that a hospital is looking at outpatient wound care. Determining the secondary motivation behind the service line will help drive your strategic planning to decide which resources and partnerships are needed. These motivations could be one of the following difficulties:

• A service line is needed to provide a consistent and reliable revenue stream.
• There’s been a “leakage” of patients to other facilities and there’s a desire to keep these patients within the current system.
• Readmission rates are affected by inappropriate wound care resources upon discharge.

Whether or not any of these reasons resonate with your hospital (or perhaps your situation relates to all three scenarios), outpatient wound care should solve a tangible problem on which to focus your efforts.

Question 2: Can your hospital support the risk of adding a wound care department?

Perhaps this question is the most important to address. Healthcare has come to an interesting juncture in our country, and every service line is feeling the panic and the pinch. An estimated $400,000-$600,000 in budgeted capital will be needed to launch a program from the ground up (including one or two hyperbaric chambers) for the build, plus additional costs for supplies and staff. It’s the initial cost that often raises concerns, as many hospitals simply can’t afford this type of service line despite apparent needs. As a result, certain organizations may consider partnering with a management company that will pay for some of the needed resources. This might make sense on paper, but there’s also a need to consider what level of control of the service line the management company may assume from Day 1. This is not something to take lightly.

Additionally, outpatient wound care and hyperbaric medicine do not have to coexist. There is nothing “wrong” with launching your wound care services first, and then integrating hyperbarics at a later time. This approach can allow clinicians to provide consistent, advanced wound care to their patient populations before determining whether hyperbaric oxygen therapy (HBOT) makes sense. This model also allows for the program to launch at a lower cost while still providing advanced wound care. As long as there’s an understanding of outpatient wound care documentation (and correct follow through), the physicians and the facility can achieve their financial goals to make these services profitable to all involved parties. If your hospital does have the resources to launch with HBOT, certain precautionary measures must be taken to ensure appropriate patient candidacy and accurate documentation.^2-4 The Office of Inspector General is questioning the efficacy and utilization of HBOT due to a history of inappropriate utilization within our industry.⁵ HBOT is an adjunctive service that, when used appropriately, can provide an extraordinary benefit to a limited number of patients. However, it is imperative that providers understand the strict guidelines associated with the therapy (or work with a partner who can assist with documentation, preauthorization, and utilization) to ensure proper reimbursement. (See below.)

Wound Care & HBOT: Program Considerations

Helen B. Gelly, MD, FACCWS, UHM/ABPM, FUHM

From a pragmatic view, the establishment of a wound care center, followed by the addition of hyperbaric oxygen therapy (HBOT), certainly can make financial sense. However, having an HBOT center without a closely affiliated wound care program presents additional challenges. Both scenarios share the common challenge of ensuring that adequate documentation is readily available should medical review be required for payment. Both HBOT and wound care (many patients receive one or both modalities as part of the care plan) are under increasing scrutiny, as evidenced by both the 2017 Work Plan by the Office of Inspector General¹ and the newly finalized local coverage determination² by Novitas Solutions Inc. Because of this increase in documentation requirements, as well as the increase in prepayment additional development requests (ADRs), this is an opportune time to review what is “requested” and what is really being asked for when a center receives an ADR. Palmetto GBA^® recently published its complex review results for prepayment service-specific HBOT, and this publication offers insight into the review process as well as the documentation requirements.³ Although these ADRs were hyperbaric-therapy specific, a critical reading of the specific “granular” denial findings³ highlights the documentation challenges that would exist if HBOT was provided without access to the medical records of an affiliated wound care service line. If the patient receives both wound care and HBOT, records from both must be sent when a request is made. For example, a request for documentation of one date of service for HBOT might be sent to the hospital and may end up in the medical records department for fulfillment. Those folks would send what was requested for that day of service (HBOT note), but not send all the additional information that is typically documented on the wound care side of the system. This would result in a denial reason for “no documentation of medical necessity — treatment plan does not include progress updates and patient’s response to therapy.”

Typically, HBOT notes do not contain the information that is included in a wound care note, such as measurements, interventions, and care plans. If the patient is being seen for HBOT alone, and wound care is being provided by the referring physician, then interval evaluations by the HBOT physician are required by the Centers for Medicare & Medicaid Services to document progress (30-day periods; mandating at least biweekly notes to document progress). These notes should accompany any HBOT-specific ADR, as well as a complete history and physical, care plan, and treatment goals. 

Helen B. Gelly is emeritus medical director of Hyperbaric Physicians of Georgia and chief executive officer of HyperbaRXs, Marietta, GA.

References

1. OIG Work Plan 2017. U.S. Department of Health & Human Services. 2017. Accessed online: https://oig.hhs.gov/reports-and-publications/archives/workplan/2017/hhs%20oig%20work%20plan%202017.pdf

2. Local Coverage Determination (LCD): Wound Care (L35125). Centers for Medicare & Medicaid Services. 2017. Accessed online: www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?lcdid=35125

3. Prepayment Service Specific Probe Results for, The Health Insurance Prospective Payment System (HIPPS) Codes For Claims Utilizing the CH** HIPPS Codes in Georgia for October 1, 2016 - December 31, 2016. Palmetto GBA. 2017. Accessed online: www.palmettogba.com/palmetto/providers.nsf/vmasterdid/aj6kcc8416

Question 3: Do you have the support of hospital leadership for a wound care program?

The success of your program will begin and end with your hospital’s executive leadership. It cannot be the “pet project” of a single clinician; it has to be part of the strategic vision of the leadership team. It’s not unusual for the authors to receive a call from a hospital’s chief executive officer asking whether the hospital should keep its wound care program open for business. This is usually at a point when the organization is 7-10 years into a program, and the “glamour” has faded. The hospital may also have cycled through a few management companies while resources have been depleted and an ill-run program is consistently in the red. However, if hospital officials decide from the moment that they launch the program that the success of the program is the responsibility of the hospital and the hospital alone, it can be both a successful and viable source of income. A management company can help optimize the service line and provide services and consulting, but the foundation for success begins when hospital leadership believes in the program just as much as the dedicated wound care clinicians who provide patient care.

Question 4: Are there committed physicians to provide leadership?

A strong physician base is critical to the long-term success of any program. Outpatient wound care runs on tight margins, and these programs can be very successful when a team of multidisciplinary physicians commits to (and honors) a consistent schedule to fill a Monday-Friday clinic. A healthy, growing outpatient wound care program should be seeing 50-125 wound care visits per week, depending on the region. Before the program launches, a seasoned medical director should be in place. This professional should have a track record illustrating a strong commitment to the community and patient care, regardless of financial gain. He or she must be a strong leader who offers consistent guidance, encouragement, and support to the hospital’s team of wound care physicians. There are attractive financial benefits for providers who practice in an outpatient wound care clinic. However, the hospital must look for a physician panel that does not see financial gain as the primary reason for joining the wound care team. Yes, things like physician supervision of HBOT and the hospital’s absorption of dressing costs (as opposed to the physicians’ private offices) are tangible benefits that should be discussed, but if the physician is only concerned with the dollar signs, they may question their commitment if patient volumes begin to dip. Your physicians should also be committed to bringing their patients into the outpatient facility and encouraging their colleagues to do the same. If they believe in the efficacy of the service line, they will become dedicated community advocates for the program.

Question 5: Is there appropriate infrastructure to support the wound care program?

Once the motivation behind the wound program has been justified, the risks have been weighed, and the leadership team has been aligned (including the appointment of a physician champion), the next step is to think about infrastructure. The day-to-day operations of an outpatient wound care program bring unique challenges that are different from inpatient care, such as unpredictability in terms of patient caseloads, unique demands or requests from the physicians, and relying on external agencies post-discharge for appropriate care (to name a few). If the hospital already has other outpatient departments, then there will be a precedent for dealing with some of the challenges. If, however, there’s no strong outpatient programs at the facility to learn from, consider seeking operational assistance. The authors recommend that hospitals look for a strategic partner to help optimize the program and provide the essentials needed to establish, build, and grow.

Particularly in the beginning stages, a new outpatient program requires monitoring. It is important to be forward-thinking to ensure that the assistance needed in the beginning will not come with too heavy a price tag, because the amount of assistance needed should begin to decrease the longer the facility is in operation. At a bare minimum, the program will need a wound care-specific electronic health record, written policies and procedures for the service line, a robust community-education program, a budget strategy for consistent growth, and a revenue cycle team that understands how to bill and code the service line appropriately. It is also imperative to establish a consistent clinical documentation review process, whether done internally or through a clinical documentation improvement specialist who reviews charts on a daily basis. Outpatient wound care and hyperbaric medicine is a heavily regulated specialty that requires clinicians and program directors to keep current on Medicare’s national coverage determinations, local coverage determinations, and private payer guidelines in an effort to save time and resources should the facility face Medicare audits or reviews. Establishing a consistent review process immediately after program launch will keep documentation clean and accurate while providing a natural accountability for physician and nursing staff to remain aligned in patient care. 

Christina Le is chief nursing officer and Melissa Bailey is vice president of corporate operations at Wound Care Advantage, Sierra Madre, CA. 

References

1. Wound Care Market by Product, Type, Acute, End User - Global Forecast to 2022. Markets And Markets. 2017. Accessed online: www.marketsandmarkets.com/Market-Reports/wound-care-market-371.html

2. Gelly HB. Update on prior authorization for non-emergent HBOT: transforming into prepayment review. TWC. 2017;11(10):28-32.

3. Gelly HB. Uncharted territory: site neutrality & hyperbaric therapy. TWC. 2017;11(1):14-20.

4. Gelly HB. The expanding scope of prepayment review for hyperbaric oxygen therapy. TWC. 2017;11(2):5.

5. Le JP-N. Lessons to learn from federal convictions of HBOT fraud. TWC. 2015;9(2):27-31.