Preparing Your Staff for Wound Clinic Launch: Comprehensive Education & Training

  Many of the principle guidelines for appropriately preparing healthcare staff for the opening of a new wound clinic from an education perspective are more true today than ever before. However, with a changing healthcare climate that includes increasing competition and decreasing reimbursement, the “must have” knowledge list for practitioners has expanded and the need to have the most comprehensive competency baseline within the clinic is imperative if it’s going to provide the best care possible for patients while ensuring that compensation for care is acquired.   Whether opening a new clinic, training new staff members, or continuing to educate existing staff within an established clinic, education that is ongoing and evolving education is critical. When thinking about training staff members, we must remember that the education should be directed at the clinical members as well as the operational, managerial and physician staffs. Each member of the clinic staff needs to understand the individual and unique roles of all other members as well as their own distinct role on the wound management team. All duties and aspects of the successful clinic relies on the effective functioning of each individual piece and how that piece fits into the overall puzzle of the cohesive working department.

Operational Function

  Anticipation of healthcare coverage changes and the implementation of the Affordable Care Act have altered the way companies look at reimbursement as well as what is expected from providers. The office manager, reimbursement staff, and coding personnel should be actively involved in ongoing education on the nuances of differing insurance carriers, required authorization, Medicare requirements for payment, current ICD-9 codes, and upcoming ICD-10 coding. Knowing where to obtain critical information about Local Coverage Determinations is a must for all financial management personnel, as is the ability to review this information routinely. Patient confidentiality and HIPAA regulations are as important for these staff members as they are for the clinical staff and should be a component of annual ethics training.

Basic Patient Assessment

  Thorough assessment of the patient population in the wound clinic begins with, at all times, a basic patient assessment. This requires us to evaluate the patient in general, not simply the wound. Critical to establishing the etiology of the wound is understanding what is going on with the patient as a whole. Just as with any other healthcare appointment, vital signs should be taken during each visit. All clinical staff members need to be educated on the appropriateness of assessing and monitoring basic vital information, irregularities in laboratory data, and the importance of medical and surgical history as well as social history components and medications. Much of this is data required for HITECH Meaningful Use stimulus funds.   Various comorbidities including diabetes mellitus and peripheral arterial disease (PAD) point us almost automatically toward particular wound etiologies. Wound specialists must also be in tune with less-obvious disease processes and the possible wound cause. If a patient is not diagnosed with PAD but has a history of cardiac disease or myocardial infarction, peripheral vascular status must be closely addressed. Certain autoimmune disorders may result in integument alteration and subsequent ulcerations. Atypical wound types are also correlated with unassuming comorbidities, an example of which is the relationship between Crohn’s disease and pyoderma gangrenosum. Differential diagnosis is critical to understanding wound etiology. Possessing a strong knowledge base in basic pharmacology is important and, as new medications are introduced into the market, providers must be aware of potential interactions with other medications as well as side effects. Most electronic health records (EHRs) in the wound care setting are programed to flag these very aspects, but should be evaluated closely and realistically. A formal vascular exam and neurological testing can be done later in the assessment by qualified persons, but basic pulses, capillary refill testing, and sensory testing should be done on each new patient. While a full gait analysis can be done by a podiatrist or physical therapist, abnormal gait and restrictions in mobility must be recognized at each visit by all who are rendering the patient care. Understanding the role of the podiatrist, physical therapist (PT), occupational therapist (OT), orthotist/prosthetist, infectious disease specialist, interventional cardiologist, vascular surgeon, orthopedist, nutritionist, and even the psychologist on the wound healing team will help providers refer their patients for the specific care they may need to augment healing.

Wound Assessment

  Clinical staff members, whether new to wound management or to a particular clinic, must be proficient in wound assessment. This can be learned through competency-based training. These competencies should include measurement; wound and skin description; photography; lower-extremity assessment; sensory testing; and basic vascular assessment including capillary refill, checking peripheral pulses, and ankle-brachial index (ABI) testing. These concepts must be a part of all new clinician orientation as well as annual competency training. Like every physiological system in the body, deviation from the norm in the integument can have multiple causes, etiologies, and compounding factors. The well-trained eye can differentiate between different types of wounds and be tuned into those with mixed etiologies. This type of skill comes with practice and working closely with seasoned practitioners.   Once etiology is determined, the appropriate staging system should be employed and staging must be done accurately. The difference in staging pressure ulcers, diabetic foot ulcers (DFUs), those related to arterial insufficiency, burns and chronic venous hypertension is all done differently. Documentation must include correct staging for clinical accuracy, reimbursement, and direction toward appropriate treatment — be it support surfaces for pressure ulcer patients or hyperbaric medicine treatments for those patients living with DFUs. The National Pressure Ulcer Advisory Panel’s stages, the Wagner Grading System for staging diabetic foot infections, and the Payne-Martin Classification System for skin tears are basic tools recommended for staging in the wound center, as is understanding the anatomical differences between superficial, partial-thickness, and full-thickness ulcers. The University of Texas’ diabetic wound classification system is another valuable tool, though a bit more labor intensive for clinic staff. Many of these staging/classification systems are built into or can be built into current wound care EHRs for ease of clinician use. The documentation used should be uniform for all staff members and, again, a comprehensive wound EHR can help accomplish this. Education on this documentation should come from the clinical manager and/or staff mentor in one-on-one teaching situations. Clinical consultants with each particular EHR company should be used to assist with understanding the nuances of the system for ease and consistency of documentation. The nurse, physical therapist, physician, and midlevel practitioner must all understand the importance of different wound characteristics and speak a common lexicon. When training staff on appropriate wound terminology, a helpful tool is the Association for the Advancement of Wound Care’s wound care glossary. A common vocabulary will help prevent documentation variances between clinicians. It is important to ensure staff is using the appropriate terminology when assessing the wound and using a universal wound language that others in the clinic are using for the same characteristics. There is a difference between “fibrin” and “slough” and “erythema” versus “cellulitis.” Having a common set of terms used in documentation makes the patient’s chart look seamless regardless of clinician documenting and throughout his or her healing process in the clinic. When describing wound color, tissue present or debrided, drainage, odor, periwound, and the surrounding skin, all members of the healthcare team must be proficient in articulating and documenting exactly what is present. The terminology used should be consistent regardless of practitioner and must support what is being assessed and treatment being rendered.   More detailed vascular assessment including ABI and the use of more specific testing equipment to measure arterial and venous patency are usually relegated to clinicians who are licensed (if required) or trained to perform these assessment techniques. Again, all of these skill sets should be tested annually, and if specific equipment is required, as is the case with certain vascular testing modalities, the competency testing should be done according to manufacturer and practice guidelines.

Treatments

  Patients come into the wound clinic expecting a high level of care with successful outcomes. Often times, these patients have exhausted all other treatment options or have been trying to care for their ulcers on their own or with a primary care physician. Wound care providers are expected not only to provide advanced healing techniques but to also be extremely proficient in rendering care. Advanced wound treatments include biocompatible wound dressings; sharp, autolytic, biologic, and ultrasonic debridement; compression therapies; application of cellular- and/or tissue-based products; offloading; pressure redistribution; hyperbaric oxygen therapy; and bioelectric modalities including ultrasound and electric stimulation. All clinical staff should be trained to understand all of these treatments and procedures and be able to articulate to the patient the appropriateness of use and the benefits of certain treatment regimens over others based on wound etiology and patient characteristics. A comprehensive orientation will allow the new member of the staff to visit other departments and clinicians to observe their techniques and particular roles in wound healing. This includes the nurse or PT’s knowledge base on physician debridement as well as the physician’s understanding of bioelectric modalities offered by the PT and OT departments to augment healing. Do not overlook those pieces that seem so simple but can be forgotten or not thought of during the clinic visit, such as gait training and assistive device prescription for those patients wearing total contact casting and other offloading devices. Specific treatment may require certain advanced training and licensure as well as certain credentialing for reimbursement purposes. State practice acts will often dictate who is able to perform which type of service(s) within a wound center and, subsequently, which levels of reimbursement the clinic may receive for said treatments. Look to Medicare local coverage determinations for documentation and licensure requirements required for reimbursement of various treatments and modalities. Many different staff members may have previous training on various treatments, but the clinic may not be eligible for payment unless performed by certain personnel.   Look at your clinic model and decide who is able to perform treatments most effectively and legally based on state practice act, licensure, and reimbursement guidelines as well as who can conduct these procedures to garner the appropriate reimbursement. These treatment tasks should be included during orientation and competency should be demonstrated at least annually. This can be accomplished through formal workshops or peer-review activities as long as accepted parameters are explicitly communicated and expectations outlined. All documentation of orientation and competency training must be kept available in the event that a reviewing or accrediting body audits the facility.

Case Management

  One of the areas most critical not only to successful patient healing but to clinic function and financial solvency is case management. Sound case management skills will ensure there are appropriate steps in place prior to a patient’s appointment and set a standard for judicious use of resources to produce the most efficient and effective route to healing for patients when they leave the clinic. Those who are case managing or handling certain aspects of a particular case must be aware of a constantly changing healthcare environment. Will the patient’s insurance cover advanced wound care services and will it cover patients in your clinic, or are they contracted with another provider? Is prior authorization needed for wound evaluation, clinic visits, diagnostics, treatments, or referral? Which insurance providers contract with which durable medical equipment and supply companies? Does the patient have coverage for prescription medications needed, or are there free options or other resources that can be utilized to achieve the best outcome?   Wound care providers must also be aware of the constraints faced by allied health members including home healthcare agencies, skilled-nursing facilities, community clinics, and rehabilitation hospitals so they are not being asked to provide a service outside their scope. Appreciation of one’s limitations and capabilities is needed in order to direct patients to appropriate and realistic care. We must respect our patients’ limitations as well. If patients are uninsured or underinsured, how do we offer the treatments that will save their limbs and perhaps their lives, and how do we do this in an outpatient department without overburdening emergency departments and hospitals? Many of these particular parameters can be covered during staff and physician meetings. A case management “champion” should be named within each clinic, often the clinical manager. This person assumes responsibility for staying current on frequent changes in the field and educates the staff at regular intervals on such changes.

Education, Onward

  Education for wound clinic staff should begin at orientation and should be ongoing. All clinic staff members should participate, including operational staff, physicians, and the clinical members. Policies should be in place defining routine competency training and staff education. All staff should be encouraged to pursue outside education as well, including journal articles, conferences, online courses, and local collegial meetings that bring healthcare providers together to discuss wound care and the like. Membership in professional organizations and associations related to wound care should also be encouraged. A portion of staff meetings can be devoted to presentation of the latest research, technology, or regulatory issues affecting patient care and the clinic. Webcast presentations from multiple organizations and providers are something that can easily fit into one’s day and be used to educate many at the same time. Be creative when educating staff and remember that the diligence and consistency will pay off for the clinic and for the patients. Valerie Sullivan is a physical therapist and a board-certified wound specialist through the American Academy of Wound Management. She is also clinical manager of advanced wound care services and hyperbaric medicine at Capital Regional Medical Center, Tallahassee, FL.