I'd Rather Switch Than Fight—Thoughts on Moving into Private Practice Wound Management

I think many of us can agree that advanced wound management (please stop saying “wound care”) has seen many changes in the past 20 years. Hospital-based wound centers have taken different twists and turns.
 
Seemingly at the mercy of "the C-suite," many of us have come to loathe hearing the sound of "important shoes" walking down the hall, which means an administrator is lurking. Indeed, profitability and viability have always been elusive to this group of individuals. Historically, they have defined the value of the wound center in terms of the volume of hyperbaric oxygen therapy (HBOT) treatments but HBOT services are at a 14-year low, based on Medicare claims data. Referrals to radiology, laboratory, surgery, cardiology, vascular medicine, durable medical equipment, and infusion services are always missing on monthly reports. Many of us fairly look on with resentment as those departments benefit from the fruits of our labor. Their productivity is always on the winning side while the needs of our specialty go ignored.
 
It's funny how nephrologists think they are the "red-headed stepchildren" of medicine. They should come on down and tour the wound center. 
 
Billing and coding complexities seem to impact our specialty unfairly. We are often viewed as “dressing change centers” when the expertise and ingenuity that it takes to heal some of these wounds is substantial. While I know that and you know that, it often feels as though hospital administrators do not care to know. The regulatory situation is also fraught with difficulties. Heaven help us with diabetic footwear. Isn't it crazy how a $300 pair of shoes can prevent a $30,000 problem? Unfortunately, wound specialists and podiatrists can’t sign the paperwork for needed diabetic footwear. Only the doctor treating the diabetes can do that—a frustrating requirement that causes endless delays and even some amputations.

Services You May Need for Private Wound Care

For many reasons, the industry is seeing a shift towards private practice-based wound centers. Maybe private practice is something you're considering. If you are, there are some key services I have found to be additive to our program, and which therefore, set it apart. If you choose to pursue the private practice route, you’ll need to keep in mind that medicine is taking a hospitality management approach these days—a Chick-fil-A experience is almost expected.
 
Are you a good salesperson? I hope so—private practice will require that you be able to promote yourself like never before. Just like any product you buy, our services are products we must sell to succeed. Not only do we have to be the best; we have to look good doing it. Couple this with the fact that our patients are notorious for being—well, our patients. Somebody has to love them, right?
 
1. Lymphedema massage therapy. This therapy is quite possibly the most effective therapy I have ever seen. In one hour, I have seen our therapists make headway with a patient’s depression, pain, mobility, and wound(s). The difference is substantial. I like to use a quality-of-life indicator (more anecdotal but still fun to ask). Most patients tell me this therapy was like flipping a switch. I have even seen this therapy save someone's life. If you have not looked into bringing this service to your advanced wound management (AWM) program, I cannot recommend it more. Private practice offers a special opportunity here. For complicated regulatory reasons, these therapists (physical therapists, physical therapy assistants, occupational therapists, and occupational therapy assistants) can only work under the direction of the physician who employs them. They can’t work “incident to” the services of a physician if they are both working in a hospital-based outpatient department. The door to providing lymphedema therapy services opens when you open a private practice.
 
2. A robust relationship with home health. Let me be clear—I mean robust. That means considering giving your personal phone number to the home health nurses. It means doing in-services and training for these companies; it means working with their materials management personnel; it means designing dressings conducive to home health nurses. It means being nice. It means encouraging these wonderful health care professionals to call you with their concerns, no matter what they are. Why? Five minutes (or less) on the phone with them can prevent a major problem and save a lot of wasted time later.
 
Always remember this: nurses do not like calling anybody. If they are calling you, it is for a reason. Being nice to them will pay you back in dividends. They will send you patients. They will market for you. They will sing your praises. If you are ugly to them, remember this: they will still market for you—it just won’t be the marketing you want. Trust me, it is not the type of advertising you want. Recognize the power of nursing.
 
I am a nurse. I know these things. Be nice.
 
3. Wheelchair company. I am not going to lie. This paperwork is truly terrible. But I have become quite skilled at doing it and the results are worth it. The eureka moment for me came when I evaluated a middle-aged paraplegic who had undergone multiple flaps and grafts with subsequent failures—because no clinician ever looked at his  wheelchair. I have also become at least cognizant of kinesiology and how body mechanics change with paralysis.
 
If someone is wheelchair dependent, it is not unreasonable to assume their wounds are caused by the wheelchair until proven otherwise. This is especially true if they have a wound on their lateral foot. Having a wheelchair company willing to see and evaluate patients in the clinic is extremely valuable. It strengthens the case to get them a new chair, it ensures things are documented correctly, it cuts down on delays via third party payer denials, and they have the best chance at getting what they need. You also learn important skills making you better at what you do.
 
4. Prosthetics and orthotics. Prescribing orthotics is one of the main things we do and I have not found it to be burdensome. In fact, patients like the service, it is convenient, and again, the skills gained in understanding this expertise can enhance how you practice.
 
When we lose a battle and a patient suffers an amputation (or is about to have one), the right prosthetic can be literally life-saving. We all have been smacked in the head with the mortality numbers following amputation. I believe the reason for this is that the health system has failed to “build a road” for patients following amputation. In my practice, when an amputation becomes unavoidable but before it occurs, our patients will have met their prosthetist, physical therapy will have been ordered, and their primary care physician will have evaluated them for depression. That way, the patient comes out of surgery ready to live. This wasn't my idea—it's what the US military does. Soldiers with traumatic amputations aren't even given the opportunity to fail—they are virtually forced to move forward. It is important to remember our patients need the same thing. Having immediate access to a prosthetist and planning for their needs after surgery are crucial to ensuring the patient gets their life back.
 
However, sometimes an amputation happens quickly—even emergently. When this happens, prosthetists and physical therapists must be consulted immediately. Here’s a tip: If you have a wound on a foot and the patient uses a prosthetic on the other leg, the prosthesis is often the reason that the remaining foot has a wound. Get the prosthetist involved.  
 
5. Infusion services. Having access to infusion services in treating complicated wounds is transformative. There are some billing and coding aspects that can also make this a financial win, too. Additionally, you can protect the patient in many ways by utilizing Medicare Part B by infusing medications rather than their Medicare Part D.

Final Thoughts

There are many wound programs that offer the above services, as well as others that I did not name. Sadly, however, there are large wound management programs that fail to offer any of them. Start by looking in your community for the gaps. Where are the care gaps and what is done poorly?
 
Once you identify a gap, fix it! You can always find reasons not to do something. What will set you apart is finding the reasons why you should. When I worked in a hospital-based setting, fixing even the simplest problem required overcoming huge, bureaucratic barriers and the inertia of a lot of people. In my private practice, if I want to do something, I do it. I will try it. I learn more from failing than from succeeding.
 
In every health system you will find a nicely appointed office occupied by a person with an impressive title whose primary function is to get in the way of improvement. And yet your hard work is why they get paid. You know who I am talking about. You may live in a different state, but it's the same everywhere. These people are hard to get ahold of and when you do, they are dismissive. They speak to you on speaker phone (a personal pet peeve of mine), offer nothing but useless words, and their solution is to refer you to some website which will explain the process.
 
Here's an idea: consider private practice.

Stephen “Andy” Rohrer, MSN, RN, APRN, AGACNP-BC, FNP-BC, CWS, is in practice in West Memphis, Ark.

Click here to download a PDF of this article.