Getting Started: The Tools You Need to Take Your Hospital-based Wound Clinic from Concept to Care

The beginning is the most important part of the work. — Plato

  Since the ancient Greeks first put honey in wounds, our comprehension of wound management has been a slow but steady journey. An understanding of the germ theory led to sterile, dry dressings and frequent antibiotic scrubs. The original work by Dr. George Winter, published in 1962, demonstrated the value of a moist wound environment. Now, recombinant DNA technology and genetic engineering hold out the possibility for growing replacement tissue s and blood vessels. Between these extremes lie semi-synthetic human skin, dermal scaffolds, hyperbaric oxygen therapy, negative pressure therapy, topical growth factors, and a billion dollar dressing industry.

  Wound management crosses all disciplines from physical therapy to plastic surgery and includes podiatry and dermatology. Within a single hospital, clinicians manage postoperative wounds from pediatrics to geriatrics, acute wounds from the emergency department to the burn unit, and chronic wounds from the intensive care unit to the long-term care unit. Some wounds improve and some deteriorate. The reality that patients with multi-organ system failure can “outlive their skin” is ignored by public policy that assesses monetary penalties for pressure ulcer formation regardless of comorbid factors. The disconnect between patient or family expectations and physiological reality can create a medicolegal quagmire for a hospital unprepared to handle the collateral damage of patients who are being admitted older and surviving longer, but sicker. Although these insidious problems are pervasive, in a large organization such as a hospital it is easy to understand why administration may not comprehend the full impact of skin and wound care issues on the institution.

  An estimated 800+ outpatient wound centers are in operation in the US, not including all the wound care rendered by clinicians in their offices. Studies suggest that patient outcomes are better when care is provided in an environment of focused expertise. To quote Dr. Allan Freedline, “… a systematic approach to wound care … leads to superior clinical outcomes, positive revenue streams, and well deserved community accolades.” These centers generate income for the hospital via tests and procedures; additionally, the wound center addresses inpatient wound care challenges, helping decrease runaway wound-related expenditures.

  A hospital has the potential to reduce inpatient length of stay and address a significant unmet need in the community when a wound center is established. To do so without exquisite preparation and planning can lead to frustration and failure. However, careful planning and early investment in resources can lead to success.

General Planning

  Key players. From the beginning, there must be buy-in both from the folks who approve plans and budgets and those who take the plan to the hospital’s Board of Directors, many of whom are leaders from the community that you will serve. The hospital’s CEO and CFO should be well informed of the options for program development and become champions of the cause. Include your medical staff office, as well as the marketing team, for ideas about future internal and external marketing needs; they are the resources who will plant informational seeds in the community, identify potential referral sources, and ascertain the perception of need in the medical community.

  Research your service area. Knowledge of the demographics of the community based on known epidemiological data can assist in projecting the potential needs. Additionally, knowing the current diagnostic trends in the inpatient population (ie, diabetes, cardiovascular disease, patients admitted with wounds) can help predict potential wound care needs.

  Location, location, location. Determine your proximity to other medical services, patient access, visibility, options for expansion, cost per square foot, and the challenges for equipment installation (eg, hyperbaric chambers). Will you be on- or off-campus? A brief consultation with your hospital legal team will help you understand the potential ramifications to your hospital’s global provider status if you elect to utilize a management company in an off-campus situation.

  Know your competition. Find out if there are other similar outpatient programs in the community. What are their strengths and weaknesses? Will you compete for the same patients or the same physicians?

  Perform a market analysis. Evaluate your service area mix, starting with the postal codes for your patients. Hospital marketing can help you assess primary and secondary service area populations to allow you to estimate payor mix.

Space Planning

  Physical plant. The clinic space must include individual treatment rooms with sinks, adequate front office space, offices, waiting area, clinical workspace, a dictation area, storage areas, and clean and dirty utility rooms. If your plans include a hyperbaric program, you also will need patient changing rooms in addition to oxygen supply, fire safety, and floor weight loading, with consideration to the wax on the floor and the types of lights in the ceiling. It is imperative to consult with individuals qualified to assist you with these unique requirements early in the planning.

  Treatment room equipment. Podiatry chairs or stretchers, Mayo stands, visitor chairs, and either installed or mobile lighting are the minimum for a properly equipped treatment room. Consider whether counter space in the treatment rooms, as well as space for documentation (electronic or otherwise), is adequate. Don’t forget the basics — thermometers, sphygmomanometers, needle boxes, glove boxes, dirty linen containers, trash cans, and hazardous waste receptacles.

  Ancillary equipment. At a minimum, you must have hand-held Dopplers and cameras. Transcutaneous oximetry or skin perfusion systems must be securely stored — if possible, installed on carts to move from room to room. Additional specialty equipment such as low-frequency ultrasound or pulsed lavage may be added later. Plan for instrumentation such as curettes, forceps, scissors, rongeurs, tissue nippers, and the like. Determine whether reusable or disposable equipment would be more effective, depending on your resources.

  Office equipment. Copier(s), fax machine(s), locking file storage, desks or cubicles, phones, and all other essential office needs must be considered. “Point of service” electronic documentation will require a computer in every room.

Operational Planning

Front office.
  Front office functions. Determine how walk-ins, registration, insurance verification, money collection, check-in and check-out processes, billing reports, payroll and timesheets, and end of month reporting will be handled.

  Privacy policies. HIPAA guidelines must be established and enforced.

Back office.
  Disposable supplies. Assess what dressings are currently stocked in the hospital. What company or supplier contracts are in place? Is there access to basic dressings — what about advanced products? Is there a procedure currently in place for ordering, tracking, and submitting patient bills for tissue replacements? Often the surgery department will have established protocols in place for acquisition of specialty items.

  Supply ordering/receiving. Who will maintain par levels? By what mechanism will supplies be assessed and shelves be stocked? How will your inventory database be maintained?

  Pharmaceuticals. How will pharmaceuticals be handled? Who will maintain this information? Who will reorder? Look at the current hospital formulary for drugs and identify what may need to be added. Consider topical and injectable anesthetics, topical creams, debriding ointments, steroids, and antifungal agents, to name a few.

  Environmental services. Establish arrangements for and documentation of clean utility, dirty utility, housekeeping, and biohazardous waste removal. Establish a plan in writing for the physical path it will take to exit the building.

Clinical Planning

  Physicians. Is there a physician champion already involved? Physician staff recruitment should commence with great care. Physician interest based purely on financial rewards holds the potential for disappointment for all parties. Ideally, a full-time Medical Director who has a passion for wound healing and can assist in attracting other multispecialty physicians should be identified. Setting the stage for collaborative practice with the other clinicians who will be staffing the clinic creates the best scenario for success. At the same time, be cautious of an arrangement where you are simply bringing together a group of physicians with the motive of gaining access to their “book of business” — ie, a starter patient load. Clear expectations for coverage, timeliness, documentation, patient recruitment, skill and education level, continuing education, and possible board certification is best understood from the beginning. Also, choosing a Medical Director who is able and willing to handle physician and staff issues will go a long way toward keeping a happy and fulfilled staff. There are also unique qualifications for hyperbaric services; medical staff services must have a description of these qualifications. Determine if there will be emergency call coverage.

  Clinic staff. The ideal situation would involve hiring nurses and therapists with wound experience but this is not always feasible or possible. Additionally, hiring in staff from other specialties — eg, critical care or the emergency room — brings in skill sets that can enhance the knowledge level of the entire staff. Wound care and healing can be taught to interested clinicians. Work ethic, individual contribution, and excellence in patient care delivery are desired attributes in each individual hired. Putting an initial training program in place and encouraging attendance at wound inservices and symposia enable educational growth for the staff at any level. Ultimately, a core group of internally recruited and nurtured experts with a cadre of assistants-in-training will go a long way in meeting your financial goals for staffing as well as providing for permanence and stability in your workforce.

Health Information Technology Planning

  Regulatory compliance. A thorough understanding of federal and state regulations, Joint Commission requirements, and coding and billing guidelines is essential to the financial health of the center. The use of a qualified consultant to assist in setting up the chargemaster, training your staff in the complexities of coding wound center visits and procedures, and establishing internally compliant documentation requirements is mandatory.

  Documentation/coding/billing. Documentation must include patient consent for treatment and photography, an initial visit and history form, regular clinic encounter and wound assessment forms, and a clinic charge form. Electronic systems can be used to create an informational database to track outcomes, build reports, show spin-off revenue to the hospital, provide reports and feedback to referring physicians, and a myriad of other information that is overwhelming to track by hand. In general, reimbursement is linked to quality of documentation.

  Physician reimbursement is controlled by complex regulations (52 pages long) from the Centers for Medicare and Medicaid Services (CMS) — they detail the specific documentation required to achieve different payment levels for initial and follow-up visits. Reimbursement increases (to a point) with number of procedures and “cognitive effort” (tests reviewed, tests ordered, prescriptions given, complexity of procedures performed, and the like). Documentation must support both necessity and the service and must be linked to the ICD-9 diagnosis code. Payment for Evaluation and Management Codes (E/M) is determined by the complexity of care based on key components (history, physical examination, medical decision making). There are 6,144 possible combinations for a visit; hence, the use of Level 4 EMRs for calculating the level of service provided is increasing.

  Levels of service. Medicare (the CMS) defines five levels of service in Outpatient Services; however, only three payment amounts are used. The CMS proposed a reimbursement system based on wound size but recent data showed this would not fairly represent the work performed in outpatient wound centers. The Alliance of Wound Care Stakeholders has endorsed use of an acuity scoring instrument that represents the amount of work performed by staff as a model for facility reimbursement. The CMS has not made final decision on how facilities will be paid.

  Electronic health records (EHRs). The key consideration in selecting an electronic documentation system is its level of functional and semantic interoperability. Many wound center planners who see the obvious benefits of a wound care specific electronic medical record are met with an impenetrable roadblock from their Medical Records, Business Office, and Information Technology Departments — a lack of sophistication in the EHR’s ability to communicate with other systems in the hospital’s Health Information Management System (HIMS). Of CIOs polled in a recent survey, 90% prefer a generic module of the hospital’s global EHR. This involves more typing, scrolling, and hunting than a specialized solution that is not at National Alliance for Health Information Technology’s (NAHIT) Level 4 of interoperability. Systems at Level 3 and below (the majority of specialized wound documentation systems) cannot fluidly communicate with the hospital’s HIMS. This means the physician can write an order or draft a document in the specialized EHR but it cannot be sent to the hospital HIMS electronically; it must be re-keyed, dictated, or scanned, opening the system to flaws and errors that expose the hospital to liability through discontinuity in the legal medical record (see Table 1). With a properly installed Level 4 EHR, patient admission information is entered in the HIMS and automatically populates in the EHR (ie, no “double entry”). Physician orders written in the Level 4 EHR are automatically sent to the HIMS’ lab system electronically. Letters and other documents produced in the Level 4 EHR are transmitted to the HIMS data repository electronically and may be viewed from any workstation in the hospital.

  Level 4 EMRs can calculate physician and facility level of service (using acuity scoring), incorporate and drive the adherence to evidence-based clinical practice guidelines, perform benchmarking, and interface with the hospital’s EMR directly. Level 3 EMRs cannot perform these functions. Users of a Level 4 EMR can obtain benchmarking analyses in comparison to other EMR users. Such a system can also track supplies, handle inventory, and perform marketing analyses and many other functions of critical import to a new wound center. While it may take more effort to work through the process of obtaining a Level 4 EMR, the dividends appear to be worthwhile.

Management Company or Not?

  Even the abbreviated description of this process is sufficiently daunting to motivate many hospitals to join with management companies in the creation of their outpatient wound centers. While such an arrangement can conservatively commit 75% of wound center revenue in the service of the management contract, “going it alone” can involve costly mistakes. The topic is up for debate.

Final Thoughts

  Planning to open a wound clinic — a massive undertaking — can cause one to lose sight of the goal — that is, to improve the care of patients with non-healing wounds. It is intriguing to consider the way wound care becomes a mission for the staff. The visual nature of healing wounds provides an emotional reward often lacking in other disciplines. Grateful patients, often elderly and in need of emotional support, find themselves uniquely attached to the wound center caregivers who often spend more time with them than any other clinicians. However, “we must do well to do good.” The wound center program must be financially successful if its mission is to be realized. In that respect, Plato was not entirely correct. The beginning may be the most important work but as Horace noted, “He has half the deed done who has made a beginning.”