Incorporating the Nurse Practitioner Into Hospital-Based Outpatient Wound Care

  It’s become common knowledge that wound healing requires a holistic approach. Any healthcare provider caring for the wound patient must consider the wound itself and all existing comorbidities beyond the wound in order to evaluate the patient’s full healing potential as related to the location and etiology of a particular wound. From the business perspective, cost-effective wound care requires attention to patient medical history (eg, cardiovascular disease), to nursing history (eg, self-care ability/education), to the elements of the moist wound healing process (eg, appropriate dressing availability/use).   As qualified healthcare professionals who are specially trained to practice within the unique blend of nursing theory and the medical decision-making model, nurse practitioners (NPs) can provide a valuable perspective to the wound care team within hospital-based outpatient wound care departments (HOPDs). However, these professionals must be set up for success upon being recruited into wound care. This article discusses the requirements needed to effectively practice wound care as an NP, the benefits of the integrated NP role in HOPD wound care, and provides practical checklists that will help both the NP provider and facility ensure a beneficial transition.

NP Requirements & Functions

  Those considering the route of NP certification into HOPD wound care have much to plan. At the current time, NPs must complete a master’s level education program in order to be credentialed. In most cases, they must also gain certification in a specialty before they can begin to practice. Adult, family, and geriatric care are key specialty areas of focus that are conducive to potential work in an HOPD. Wound care certification is a crucial addition to education for any NP who seeks to work in an HOPD due to the important details regarding chronic wound diagnosis, treatment, and healing that remain absent from most nursing and medical education programs. A nationally recognized wound certification is certainly the most reliable way to ensure an acceptable baseline understanding of wound care. Some national certifications require wound care experience in order to sit for certification. Other national certifications offer an option to establish eligibility for certification by successfully completing an accredited educational program. Either way, as in all specialties, successful wound care experience can play an important role in NPs promoting their expertise to an HOPD.   Just as with physicians, an NP must have expertise in all procedures performed within the HOPD. NPs can also provide “direct supervision” for procedures performed within an HOPD as long as they are “immediately available.”    (NOTE: “Immediate” has not been defined by the Centers for Medicare & Medicaid Services (CMS), either to time or distance. Hospitals must define “immediate” by keeping in mind the safety and quality of care for their patients. The provider must be interruptible and able to be physically present to furnish assistance and direction throughout the performance of the procedures.) Without this direct supervision, HOPDs may not bill the Medicare program. Typically, HOPD staff performs procedures such as application of multilayered high-compression bandage systems and application of negative pressure wound therapy. HOPD-qualified healthcare professionals should also be proficient in surgical procedures, including debridement and tissue biopsy. A direct supervision role requires expertise in all of these procedures as well as any other services/procedures performed in a HOPD. NPs usually practice in HOPDs under their own National Provider Identifier (NPI) number acquired through the National Plan & Provider Enumeration System. As is also the case for any qualified healthcare professional, NPs are required to purchase malpractice insurance. Many US states require NPs to receive some level of oversight by a medical doctor (MD).   Liability and insurance premiums for MDs do not increase because of a collaborative relationship with an NP. Furthermore, actuarial data has shown the incidence of lawsuits against NPs is lower than the incidence of lawsuits against MDs.¹

NP Practice Autonomy

  Although the role of the NP related to wound care and healthcare in general has grown exponentially, there do remain hurdles that many practitioners still face before they are allowed to work within their scope of practice. There are currently 17 states, plus the District of Columbia, that allow independent NP practice. Within the remaining 33 states, NPs cannot practice without developing a contractual relationship with a physician, which involves a written protocol defining NP practice. In 10 of these 33 states, this contract involves delegation of activities to the NP by the physician and supervision of the NP’s practice. In the remaining 23 states, physician involvement provides a less restrictive, collaborative format. The details of these NP/physician relationships vary from state to state. For example:     • NP practice in Utah requires collaboration only for the prescribing of Schedule II drugs. (For more information on the prescribing of Schedule II drugs, see “Managing Pain Medication in the Outpatient Wound Clinic” in this issue.) An NP in Utah can independently diagnose and treat as well as prescribe most pharmaceuticals, but requires MD collaboration to prescribe Schedule II drugs.     • NP practice in California requires general physician supervision/delegation to practice, but not national certification.²   It is interesting to note that in 11 of the 33 “non-autonomous” states, an NP does not require physician involvement to diagnose and treat a patient.³ Adding these 11 states to the 17 states (plus District of Columbia) that support autonomous practice, we have nearly 30 US states that allow NPs to independently diagnose and treat patients without physician involvement. Most of the wound care processes that occur in an HOPD involve diagnosis and nonpharmaceutical treatment, guidance of outpatient testing, various procedures, specialist referrals, ordering of durable medical equipment, and a significant amount of patient education. Therefore, NPs in these states who hold wound expertise can effectively manage and heal wounds without significant need for physician involvement, except for, perhaps, prescriptions for an enzymatic debrider or antibiotics. With physician involvement, NPs in these states can, of course, prescribe. If we could develop a greater national respect for the “science” of wound care, a respect that would support more timely referral from the generalist provider (remember wound science is absent from most nursing and medical educational programs) to the professional wound care setting and specialists, then we could significantly decrease incidence of wound infection/complication and the subsequent need for prescriptions.   Oddly, at the same time that healthcare reform is promoting new respect for the NP’s role, a new challenge is developing for NP wound specialists who are required some level of MD involvement in order to practice. There is a growing trend toward refining and matching NP/MD specialties. Unfortunately, “woundology” is not a recognized medical specialty. This, coupled with a growing awareness that wound care must be addressed holistically to involve aspects of cardiology, podiatry, dermatology, endocrinology, surgery, neurology, rheumatology, etc., is making it more difficult to find a satisfactory blend of NP/MD specialties. To prevent risk of a figurehead role and to support optimal-care provision, this quandary supports the need to promote respect for both the science of wound care and for those qualified healthcare professionals who currently demonstrate wound care expertise. Since both of these efforts remain ongoing, it is particularly important to the national goal of high-quality, cost-effective healthcare delivery that the novice wound care NPs who must receive practice supervision choose an MD with a wound certification and significant wound care practice experience.

NP & HOPD Business Options

  Much like the level of autonomy and supervisory structure that an NP practices within a given state will vary, the practice and business model for NPs in an HOPD includes three general options. 1. NP Employed by the Hospital   If the NP is already a salaried employee of a hospital and is providing care to acute patients, the hospital is accounting for the cost of the NP on their acute care “cost report.” If the NP decides to move to the HOPD, he/she must be removed from the acute care cost report because, logically, his/her work can no longer be bundled into the costs of that setting. When the NP becomes a salaried, qualified healthcare professional in the HOPD, he/she will transfer his/her NPI number to the hospital, which will use that number to bill for the NP’s work in the HOPD. NOTE: It is difficult, but not impossible, for the NP to retain inpatient and outpatient responsibilities as a salaried hospital employee. Careful attention must be paid to the risk of overlap between accounting for the NP in the acute care cost report and billing with the NP’s NPI number for services performed in the HOPD.   In May 2012, CMS made the decision to support the right of hospitals to grant privileges to NPs.⁴ If this scenario evolves to practice, an NP could work as a hospital consultant, similar to how many of today’s physicians practice. The wound specialist NP could assist with acute wound care delivery and could be removed from the hospital’s cost burden. This would lead to a more fluid NP practice environment, which could more easily include the traditional fee-for-service acute and post-acute (includes HOPD) settings as well as the accountable care organization environment. Some physicians have voiced concern that expansion of NP practice could negatively impact the finances of physician practices. However, recent analyses reported by the 2012 National Governor’s Association Paper “The Role of Nurse Practitioners in Meeting Increasing Demand of Primary Care” dispel this concern to be unsupported by fact.⁵ Physician income has not dropped in states that have granted increased NP autonomy due to complimentary MD/NP roles. Furthermore, these states have enjoyed an overall increase in thoroughness and quality of care delivered to their residents. 2. NP Within Physician Group   If the NP is a salaried member of a physician group practice, he/she transfers his/her NPI number to that practice. When the NP provides independent service in the HOPD, the group practice submits claims to the insurance company via the NP’s NPI number and identifies that the services were provided in the HOPD. Typically, this arrangement will require a contractual practice agreement, which should include a practice protocol between the NP and a group physician. While working in a physician group, this author developed a generic wound treatment protocol that was kept on file at the practice site and in the HOPD. 3. NP With Independent Practice   Within all states where NPs have the option to begin an independent practice, he/she must practice within state practice guidelines, many of which involve some level of physician collaboration including a protocol to define care guidelines. To practice in an HOPD, the NP must also be credentialed by the hospital system as an approved provider of care within the HOPD. Credentialing involves a review and approval of the provider’s credentials, capabilities, and practice structure. In the independent practice model, the NP bills under his/her assigned NPI number for wound care services provided in the HOPD. The key business consideration for the NP is to identify which insurances recognize NP practice and under which situations. For example, Medicare fee-for-service is very supportive of NP practice and reimburses the NP 85% of Medicare’s physician fee scale. However, some Medicare HMOs or Medicare Advantage plans do not reimburse NPs. For dually eligible (Medicare and Medicaid) patients, supplemental Medicaid programs generally reimburse NPs the remaining 20% of the Medicare allowable. Beware: not all state-sponsored Medicaid programs allow NP participation. Many private insurance companies will only reimburse an NP who is contracted with a credentialed physician, while others continue to refuse to recognize any level of reimbursement for an NP in independent practice.   As our population ages and chronic wounds prevalence increases, HOPDs will continue to be seen as valuable resources. Refer to Table 1, a checklist that NPs should consider, and Table 2, a checklist that HOPDs should consider, for ensuring optimal NP placement. Jennifer Hurlow owns her own NP practice: Wound Practitioner LLC, Germantown, TN. She may be reached at jenny.hurlow@gmail.com.

References

1. Hooker R, et al. Does the employment of physician assistants and nurse practitioners increase liability? Journal of Medical Licensure and Discipline. 2009;95(2):6-16. 2. State practice environment. American Association of Nurse Practitioners. Accessed online: www.aanp.org/legislation-regulation/state-practice-environment. 3. Nurse practitioner prescribing authority and physician supervision requirements for diagnosis and treatment, 2011. Kaiser State Health Facts. Accessed online: www.statehealthfacts.org/comparemaptable.jsp?ind=890&cat=8. 4. Turner S. CMS broadens concept of hospital ‘medical staff’ to provide greater opportunities for nurses and other nonphysician practitioners. Geriatric Nursing. 2012;33(4):302-3. 5. The role of nurse practitioners in meeting increasing demand for primary care. NGA Center for Best Practices. Accessed online: www.nga.org/cms/center.