Yearly Checkup: Is Your Wound Care Clinic Successful?

  Kathleen D. Schaum, MS, Founding Editorial Board Member of Today’s Wound Clinic, and President of Kathleen D. Schaum & Associates, Inc., Lake Worth, Fla., is the go to source for information regarding coding, coverage, and payment for the staff of Today’s Wound Clinic. Every issue of TWC is extremely enhanced with her contributions in the InBusiness section, providing invaluable advice for wound care professionals. In this issue of the journal, Schaum’s section addresses the topic of “Is This Wound Clinic Financially Successful? And Where Can I Find Medicare Payment Regulations?”

  For this special extended cover story we asked the remaining four Founding Editorial Board Members to continue on the discussion started by Schaum, offering additional elements that may be used to measure and create a formula for success.

Supervised Neglect and the Concept of Excellence

  Caroline Fife, MD, FAAFP, CWS, and Co-Editor of Today’s Wound Clinic

  Three recent self-referred patients have gotten me thinking about what it means to be a ‘wound center.’ I read Kathleen Schaum’s article in the Inbusiness section of this issue and clearly wound care services are successfully delivered in a variety of settings across the United States. I don’t think that the place of service is the issue.

  This topic directly relates to three of my recent patients. All three patients I have treated in the past 3 months.

Patient A

  Patient A—is a 30-year-old white male with a one-year history of a small non-healing ulcer on the dorsal aspect of his right great toe. He had been followed for a year at another wound center in my city, using a variety of topical products. When I questioned him carefully, despite his young age, he had symptoms consistent with claudication. I performed vascular screening as I do with all patients who have non-healing lower extremity ulcers. His transcutaneous values were single digits and his pulse volume waveforms were a flat line. The short story is that he required a peripheral bypass for his severe vascular disease. An MRI also showed that he has osteomyelitis of the great toe for which he is now undergoing aggressive surgical debridement. Both of these limb-threatening diagnoses were overlooked at the other facility where he was followed for 12 months.

Patient B

  Patient B—is a 62-year-old Caucasian woman with lower leg edema and a large wound on her right calf. She has a long history of spontaneous leg lesions and bowel disease. She had been treated for a year at another wound center with compression bandaging. While the compression bandaging was adequate, the problem is that they never performed a biopsy. Her clinical history (including the bowel disease) and the visual appearance of her lesions are textbook for pyoderma gangrenosum but she has never been told she might have anything other than venous stasis, nor has she undergone an appropriate work up for this. Her biopsies are not back at the time of this writing, but many of her other laboratory tests are grossly abnormal, including hemoglobin of 10, so she is also scheduled for a much-needed colonoscopy.

Patient C

  Patient C—is a 55-year-old African American male with type II diabetes and peripheral neuropathy who has a first metatarsal head lesion. He had been followed for 6 months at another wound center with a variety of topical preparations and multiple debridements, but he has never been prescribed adequate off loading. Our treatment plan for him is a simple one: total contact casting. I expect his lesion to be healed in a few weeks.

  All three of these patients have had what may be called ‘supervised neglect.’

   ‘Supervised neglect’ is a term commonly used in dentistry, referring to failure to properly treat periodontal disease. Only recently has it begun to be recognized as a problem in medicine. The International Center for Limb Salvage in Geneva (www.gfmer.ch/ICLS/Homepage.htm) provides information on the effect of supervised neglect among patients with limb threatening vascular disease. According to the ICLS: "Supervised Neglect is a faulty medical treatment that fails to inform patients of more effective treatments for their aliment: the treating physician therefore enforces therapies that are either not up to date or ineffective. Patients, treated this way, receive attentive follow-up and frequent medical exams. … This conduct enforces the illusion of being properly treated due to close medical supervision when, in effect, ineffective care is being given.”

  And that gets us back to the question of ‘what is a wound center?’ For 6 to 12 months all of these patients were treated at facilities advertising themselves as ‘wound centers.’ However, these facilities did not provide vascular screening for a non-healing leg ulcer, a biopsy for a suspicious leg ulcer, which had failed to respond to conservative management, or off-loading to a neuropathic ulcer. The patients thought they were being seen at a wound center that specialized in diagnosing and treating wounds. The hospital advertised that they had a wound center, and certainly they had lovely websites touting their particular services and their commitment to ‘patient centered care.’ What went wrong for these patients?

  At first I thought that the answer was to be found in the concept of ‘Centers of Excellence.’ The basic definition is that a center of excellence is a healthcare facility selected for specific services based on criteria such as experience, outcomes, quality, and efficiency. Centers of Excellence have been developed for radiotherapy, cardiovascular procedures, and many other highly technical fields. Outside of the medical field, it is defined as a team of people that promote collaboration using best practices to drive results. It does not matter whether the team is staffed with full- or part-time members.

  While we may be able to argue that it is time for a similar initiative in wound care, it occurs to me that the answer for my three patients is an easier one. All three of these patients required only that national guidelines for the evaluation and treatment of their diseases be followed. These national guidelines have been exhaustively spelled out by many organizations such as the Wound Healing Society, The Association for the Advancement of Wound Care, the Wound Ostomy and Continence Society, and others. Many are freely accessible online and all the national wound care meetings—including the SAWC & WHS Spring and Fall—provide superb opportunities to obtain CME credit while learning how to implement them.

  The discussion about wound care services is not about who or where, but about what. Among other basic interventions, all chronic non-healing leg ulcers require vascular screening, all neuropathic foot ulcers require adequate off-loading, all venous ulcers require adequate compression, and all suspicious lesions require biopsy. Clinicians in wound centers need to be familiar with these national guidelines. A wound center cannot be organized simply around the provision of a specific modality or intervention (eg, hyperbaric oxygen therapy, electrical stimulation, etc.,), although many therapeutic options may be provided. There must be someone who is able to perform a complete medical assessment, take a thorough history, carefully examine the patient, order the necessary diagnostic tests and evaluate the results, and then synthesize all this information appropriately to create a plan of care.

  The three patients I described above had the illusion of being properly treated because they were being followed closely, but in fact, they were receiving ineffective care. Effective care in these cases was not complex and difficult and did not require highly technical skill or diagnostic brilliance. It only required adherence to basic wound treatment guidelines. I would submit that a Wound Center is any facility, which is capable of, and consistently does follow national guidelines for the diagnosis and treatment of chronic wounds. If there is something basic that your center is not able to provide (eg, vascular screening or total contact casting) then you need to fix that. If you have the capability of providing a service but you don’t do it consistently (only some patients get vascular screening), then fix that. Of course this raises the question of how to bring national guidelines to the bedside, a great future topic for TWC. In the mean time, what we need is consistently good care for our patients.

  Caroline Fife, MD, is Co-Editor of Today’s Wound Clinic, a Founding Board Member of TWC, and a Board Member of the Association of Wound Care. Fife is the Director of Clinical Research at the Memorial Hermann Center for Wound Healing in Houston, Tex. She can be reached at cfife@intellicure.com.

Multidisciplinary Care For A Multifaceted Healthcare Population

  Valerie Sullivan, PT, MS, CWS

  A successful wound clinic, in this author’s humble opinion, is one that utilizes a diverse, multidisciplinary team to achieve a common goal. A team with differing perspectives, education, areas of expertise, and professional eyes helps to bring a more rounded healing approach to a complicated patient population, helping to improve outcomes.

Members of the Team

  Doctors of many specialties. We shouldn’t limit our centers to just one or two medical disciplines. We should actively recruit podiatrists, general surgeons, vascular surgeons, plastic surgeons, dermatologists, hyperbaracists, internists, infectious disease specialist, endocrinologists, and physiatrists. Because of time and office constraints, many of these practitioners may not want or many not be able to work a weekly clinic but could work part of a day every 2 weeks or once a month. Or they can work closely with clinic staff when our patients are referred to them for specialty care so that the patient is not ‘lost’ to the clinic. When recruiting physicians, looking to those who are winding down their careers but still have a strong interest in patient care (without all of the call time) and are interested in learning best practice in wound management, can be a valuable asset to the clinic roster.

  Nursing staff from all levels. When opening a wound center, one of the first positions sought is a wound certified nurse. This person has demonstrated a very strong dedication to wound management by continuing his or her education to gain certification. Also to be included on staff should be ARNP’s, BSNs, RNs, LPNs, Gns, and CNAs. Nurses from varying backgrounds have different types of patient care skills and communication techniques that they can bring to the table when caring for the diverse population that comes through our doors.

  Rehab specialists. Physical Therapists have been augmenting wound healing and integumentary care for many years using advanced treatment modalities that include electric stimulation, high and low frequency ultrasound, diathermy as well as different types of hydrotherapy and debridement techniques. PTs are also key in helping our wound care population to improve function, strength, flexibility, mobility, and gait. In wound centers, we routinely wrap patients in compression dressings, utilize special footwear, and casting for offloading subsequently altering a patient’s routine gait pattern with these interventions. It is imperative that we ensure the patient’s safety by teaching them safe ambulation with or without an assistive device and give them the tools that they need to redistribute pressure as well as move safely within their own environment. Mobility training can also give our wound patients the tools needed to better care for themselves including dressing changes, donning and doffing compression garments and self assessment of skin. These skills are crucial to empowering the patient and making them a partner in their own care. Occupational Therapist assist our patients in routine Activities of Daily Living (ADLs). This training improves patient self-care, transfer abilities and even daily hygiene issues that can and often exacerbate wound healing.

  Case Mangers and Social Workers. The chronic wound care population is a unique subset of patients, often with multiple comorbidities and contributing factors, all complicating care. Case managers and social workers who have a good grasp on social services, transportation, insurance benefits, and overall community assistance that is available, make not only the patient’s lives much better but greatly decrease the workload on the clinician.

  Specialized clinicians. Lymphedema therapists, Diabetic Educators and Dieticians can be some of the most valuable members of our team. These are the specialist that can help the patient to control the disease process and etiology of the ulceration in many cases.

  Coders and Billing Personnel. One of the most trying aspects of wound center management can be billing and reimbursement. Rules change frequently, documentation requirements seem to the clinician to be in constant movement and small mistakes in routine billing can be not just costly but financially terminal to the business that strives to save limbs and lives. Coders and billing personnel can greatly impact not just the ‘bottom line’ but can lessen the frustration clinicians and managers feel when dealing with various payors.

  Vendors. Though not employees of the center or the hospital, vendors can be a very valuable member of the wound healing team and should be embraced by the staff. These folks are seen not just by our staff members but also by patients and their families. It is not abnormal to have a vendor present to assist with in servicing staff on new techniques and products. Patients need to feel as though every person that they come into contact with in your facility is helping them to achieve a positive outcome. If they feel confident in the clinician and the vendor teaching the clinician, the patient will have more confidence in trying the new dressing, wrap or technique.

  Our vendors can also be a valuable marketing tool for us. Most of them not only call upon our wound centers but also call upon those that refer to us, including physician’s offices, other types of facilities and home health care agencies. If the vendor feels a part of our team, he or she is more likely to mention the clinic and do so in a more positive light than the vendor that is treated like and outsider.

  Administration. Hospital owned clinics are governed by the hospital administration. Invite your administrators in. Ask them to join the staff for in-services, meetings , and lunch and learns, etc. Make your administrator comfortable in your clinic and aware of how the clinic functions. If they are familiar with your staff and operating practices, they are more likely to understand and respond affirmatively when you ask for more staff, capital equipment or upgrades. You are no longer just that clinic across the street or down the road from the hospital but you are an active part of ‘their hospital.’ They have seen first hand what you do and will have a better understanding of what you need.

  Val Sullivan, PT, MS, CWS, is a TWC Founding Editorial Board member and the Clinical Manager of Advance Wound Care Services and Hyperbaric Medicine at Capital Regional Medical Center in Tallahassee, Fla. She can be reached for questions via email at Valerie.Sullivan2@hcahealthcare.com.

What Makes a Successful Wound Program

  Chris Morrison, MD

  We all should be grateful that wound care is now being ‘unofficially’ recognized as a specialty and most hospitals are now at least considering a wound care program if they don’t already have one. However, this breeds competition in the marketplace and we would all like to think that our own program is the ‘flagship’ program in our given communities. It is no longer good enough to just hang a sign that says ‘wound clinic’ and expect to be flooded with patients—we need to show our referring physicians that we truly are the best in order to gain their trust and their referrals.

  I have personally been involved with the development, implementation, and management of many different wound centers across the country and each community, hospital and medical staff has their own ‘personality.’ It certainly is not a one-size fits all scenario when it comes to incorporating each of these personalities into a successful multi-disciplinary program. However, if enough time and effort is placed into a few crucial categories then the road to success is not as difficult as one may think.

Physician Guidance

  Traditionally, wound care has been a nursing and/or physical therapy driven specialty and I have learned the majority of my wound care skills from some of the best in the business! However, as our understanding of the pathophysiology of wounds has increased exponentially, coupled with the breakthroughs in advanced wound healing modalities, wound care has evolved into a physician-driven specialty. In my opinion, the most successful programs will have a physician ‘champion’—ideally one who is passionate about wound healing and has devoted their medical career to the furtherance of wound care as a specialty. Some programs have a single physician model while others are successful with a panel of physicians—being determined again by the ‘personality’ of the medical community. Either way, make sure there is a physician who enjoys learning about wound care, educating the staff, and who feels comfortable implementing and disciplining other involved physicians when necessary. If one does not stand out initially, then be patient as most doctors don’t know they have the wound care bug until they are bitten.

Education

  Invest in educating your wound care staff and involved physicians —not just initially, but on a continual basis. Not only does this keep your clinic abreast of the most up to date treatments and practice standards for advanced wound healing, but it keeps them interested and out of the ‘rut.’ We all want to be leaders in our field, so show your staff you expect that from them and usually you will get it. It also shows that you value them and helps to build confidence, camaraderie, and excitement about their daily work life.

Marketing

  What good is a quality wound clinic if nobody knows about it? Spend time and money on developing an appropriate marketing plan, not just commercials and billboards, but relationship development with the community. The best marketing is education! Educate your patients, referring physicians, and hospital administration as to what you do. I do think it is important to visit current and potential referring physicians on a regular basis just to show your face, drop off a brochure, and bring donuts. But, be much more aggressive with medical lectures (grand rounds, etc.), attending hospital and medical staff meetings, sending letters to communicate with referring physicians and spend time in the physicians lounge—these are the keys to any successful medical practice and wound care is no different.

Partnerships

  A successful wound center does not function independently—there are many external pieces, which require partnering in order to bring the highest quality of care, communication, marketing, and education to the clinic. Of course, you must have a quality relationship with your hospital and its administration. Spend time communicating with the key players—regular meetings, casual drop-ins, and let them know that their support is appreciated. Another key partnership is with the pharmaceutical companies and their representatives. They are excellent sources of education and marketing—usually at no cost! Don’t push them away, but help them to feel as if they are part of your team and you will see the value they can bring. Use them to learn about evidence-based studies, provide products to the underserved patients and familiarize yourself with new products. Remember that a lot of wound care is trial and error and if you don’t know what to try you may have a hard time finding the solution. Other key relationships to develop are with other community medical services that you use frequently—home healthcare, orthotics and prosthetics, retail and compounding pharmacies, support surface companies, medical supply stores, etc. Without the support of these key components the wound clinic will never reach its full potential.

Documentation

  With today’s level of scrutiny of medical billing, coding, and reimbursement it is more important than ever to document appropriately. It is hard enough proving to CMS and other third party payors that wound clinics not only are a necessary service, but also can actually save them money, so we must document the reasons we do what we do at each visit with a patient in its entirety. If not, it is difficult to show what our thought processes are and that our expertise is worth their money. A full-service wound care EMR can help with efficiencies and reimbursement greatly when used appropriately. Spend time developing templates to follow, keeping up on appropriate codes, terminology and medical necessity parameters. Although mostly seen as the bane of our existence and a waste of time, it is a necessary evil in today’s world and it is best to play the game. It is hard to keep doing what we love if we can’t get paid for it.

Outcomes Tracking

  Along the same lines as documentation, it is no longer going to be enough to show why we do what we do, but that it really is making a difference. We all know that we will eventually be graded on our outcomes and, if done appropriately, this could be a great thing to improve our healthcare system. New EMR programs allow for outcome tracking and reporting which, if used appropriately, can improve practice patterns and efficiencies, can improve financial outcomes and can be a very important marketing tool to all players and payors. Make sure that you use these reports as they are extremely valuable now, but will be even more so in the future.

  We all strive to provide the highest quality of care to our patients and with the appropriate level of passion, teamwork and these principles you are well on your way to a successful and competitive program.

  Chris Morrison, MD, is the Medical Director, Bayfront Medical Center Wound Care and Hyperbaric Center; Medical Director, St. Joseph’s Hospital Wound Care and Hyperbaric Center. For more information email Morrison at nautilus.healthcaregroup@verizon.net.

What Defines A Wound Center?

  Dot Weir, RN, CWON, CWS, and Co-Editor of Today’s Wound Clinic

  I was at a small meeting once where the participants introduced ourselves one by one, giving the usual information: our background, how long we had worked in wound care, where we worked, etc. When it came to one of the physician’s turn, he said, “I work in a wound healing center … we don’t just care for wounds, we heal them. I recall thinking how clever that sounded, and also feeling a bit smug because the clinic I work in also has Wound Healing Center on our front door.

  For this issue of Today’s Wound Clinic, we have been asked to try to define what a wound center is. Pushing editorial deadlines to the last minute and beyond most of the time has served me well for this issue. It has given me the opportunity to first read the words of both Kathy Schaum and Dr. Caroline Fife. And having done so, we could probably just stop there, because they have so clearly articulated both the business side as well as the clinical approach that absolutely must be taken in order to provide care in an appropriate, logical, and safe manner. The cases that Dr. Fife cited are repeated in wound centers so often; the venous ulcer present for 6 months on a patient who has actually heard the word amputation, yet heals in 3 weeks with adequate compression; or the plantar neuropathic foot ulcer treated with local care for a year, only to heal in 4 weeks with a one good debridement and a contact cast.

  Dr. Fife discussed the use of published guidelines to direct comprehensive care; these guidelines are not only published, but evidence based, and validated. And many of the recommendations found in the guidelines, particularly from the standpoint of arriving at the correct diagnosis or diagnoses, require the close collaboration of a physician or extender licensed to order and prescribe the necessary labs, imaging or vascular studies, or to perform the biopsy needed to provide adequate medical management. This also then provides the information needed for the team to arrive at a treatment plan. I have heard my friend and Medical Director, Walt Conlan say the words “we have to be goal directed” to patients at least 1000 times since I have worked with him. Those goals can only be set when armed with adequate and appropriate diagnostic information to allow us to design the treatment plan that will lead the patient to healing.

  This in no way diminishes the value of my part of the care equation: the PT, WOCN, CWS or other clinician involved in the care of the patient. It takes a team. It takes the skilled execution of the treatment plan, the wraps, the casts, the dressings, the patient education, the careful documentation, the advocacy for adequate pain management, the follow-up; all of those things that get the patient through the episode of care and back to a better quality of life than when they arrived. Over the years I have heard clinicians, both PT’s and WOCN’s alike, express concern over loss of autonomy when contemplating working in a clinic operating under a physician’s plan of care. If organized and developed the right way, that could not be farther from the truth. I love that the thoughts and opinions of all of the nurses and the therapist that we work with are not only heard but count. I love our little ‘team conferences’ in front of the patient, which includes them as a decision maker. I love that there are things that we do that make sure that the patient gets the equipment, footwear, prescriptions, letters of medical necessity, work releases, disability paperwork, coordination of care with the home health agencies and skilled nursing facilities in our area, and all of the other critical components to pave that pathway to healing. And I also love that our editorial board agrees.

  So perhaps the more important question is ‘How Do I Not Define A Wound Center? Not just by the site of care, as long as all of the components of appropriate and comprehensive management are there. Not just by how you bill, as long as you follow the rules. Certainly not by how busy you are, we could schedule patient visits three times a week and be insanely busy.

  In fact, my measure of success is the number of new referrals we have per month; that for me defines community confidence. And I certainly don’t define a wound center by what is written on our door or our cards or stationary. That’s all semantics. I refer the reader back to all of this, and then recommend introspective reflection and individually define if you consider your place of care a wound center. As Caroline Fife stated, there are things that can be fixed and the help available to do so. That is the goal of Today’s Wound Clinic: to make all of us as managers, practitioners, and clinicians the best that we can be; and then to echo the ending of Dr. Fife’s article, to bring “consistently good care to our patients.”

  Dot Weir, RN, CWON, CWS, is the Wound Care Director for Osceola Regional Medical Center in Kissimmee, Fla., Co-Editor of Today’s Wound Clinic (TWC), and Founding Editorial Board Member of TWC. For more information, Weir can be reached at Dorothy.Weir@HCAhealthcare.com.