Illinois agency’s wound care preparation pays off
Education, review smooth transition to PPS
As agencies adjust to the new demands of the prospective payment system (PPS), one area of concern has been a patient with wounds whose complex care and supply costs can strain budgets.
But one Joliet, IL, agency has seen a smooth transition, thanks to thorough preparation of staff and a review of the wound care program to ensure its effectiveness and efficiency.
"We could see the writing on the wall," says Sharon Baranoski, MSN, RN, CWOCN, and director of Silver Cross Home Health, a hospital-based agency. "We started preparing for this about three years ago — really starting to look at cost-effective measures and educational components."
Baranoski says agencies can adjust to wound care under PPS by providing specialized help to nurses, reviewing and standardizing supplies, and promoting a multidisciplinary approach.
When Silver Cross began its review of wound care prior to the rollout of the interim payment system, Baranoski says the first order of business was to assess the nurses’ level of competence — and comfort — with wound care skills.
"We had a meeting with our entire staff and did a needs assessment of what they felt their skill levels were in wound care," she says. "We had an open discussion of what they were comfortable with and what they weren’t. What they felt they needed and what they already knew really well."
She says she was surprised to find that some nurses weren’t completely confident in their own wound-assessment skills. She found that the nurses weren’t necessarily lacking in the skills, but needed validation — "They needed someone to come out and say yes, I agree with you." It was a role that Baranoski, with her own wound ostomy training, was able to provide one on one as she accompanied nurses on rounds.
"I spent a day with everybody," she says. "We went out and saw all kinds of patients to see what [nurses’] skill levels were. I wouldn’t tell them the answers, but I’d ask them to tell me what they saw and thought."
She says the support helped give the nurses confidence in their personal assessments. "Some of them even said, Wow, I’m so glad to know that I am doing this right, because you never really know for sure.’"
Silver Cross held regular inservices on all aspects of wound care, including conducting assessments and learning about the range of wound care products on the market. The agency tapped company reps, as well as the hospital’s wound ostomy nurses, to provide information on using supplies.
"We did some training on how to apply and take off dressings appropriately and how to do certain types of compression therapy appropriately," she says. We did mini-competency testing on different practices."
Baranoski also standardized the terminology staff were using in their documentation to provide continuity in patients’ charts.
"We had nurses calling a bedsore a decubitus, and other nurses calling it a pressure ulcer," she says. "On any given patient chart, you could read documentation from different nurses using different terms. We needed to have some kind of standard to it so when we were reading each other’s charts or picking up a case for a nurse, everyone was of the same mindset."
Nurses were instructed on the correct terms to use — in this case, pressure ulcer — and they reviewed the meaning of all the terms used in wound care documentation. Pictures describing conditions such as granulation and contraction helped drive the point home.
Creating consulting role on staff
After a six-month period of assessing and augmenting nursing skills in wound care, Baranoski knew the staff would need more specialized help to continue the progress.
She hired a wound, ostomy, continence nurse (WOCN) to serve as a consultant to the nursing staff — reviewing charts, occasionally making rounds with nurses , keeping up with improvements in wound care, and serving as a resource when nurses had specific questions.
Unfortunately, Silver Cross’ first wound care nurse left after a short time. "Home care wasn’t what she really wanted," Baranoski says. She then took a different approach, looking internally to find a home health nurse with clinical and administrative experience and to train in wound care.
She was aided in this effort by Silver Cross Hospital’s Wound Center. "We sent the nurse to work with our WOCNs in the hospital, and they trained and educated her in wound care," Baranoski says. "She had been involved in wound care in little bits and pieces through- out her career so it came to her naturally."
While the nurse is not a certified WOCN, she has the necessary skill level, Baranoski says. "And when she gets into any situations where she’s not comfortable, or needs someone to case-conference with, then she case-conferences it with me."
The new wound care nurse has become a valuable resource for the nursing staff who come to her with referrals and questions. "She’s quite busy," Baranoski says.
She adds it’s vital to have someone with wound care expertise monitoring an agency’s progress.
"Someone — whether it be an administrator, a nurse assigned to the role, or a WOCN nurse — has to be monitoring what’s going on with the staff, what’s going on with the patients, what’s going on with the products," she says. "Finding the right person to be that wound nurse is a very important part of the efficiency and effectiveness of a program."
Home health agencies already have expressed concern that Health Care Financing Administration policies regarding supplies will make caring for wounds under PPS a real challenge.
The final PPS rule does not provide case-mix adjustments for supplies, instead including an average supply cost in every episode payment. Agencies handling significant numbers of wound care patients could find themselves losing money under this system.
In addition, under the current interpretation of PPS, agencies are responsible for providing nonroutine supplies, even those unrelated to the care they are providing.
The home health industry currently is petitioning Congress for changes that would eliminate some of those burdens. But in the meantime, Baranoski says it’s more important than ever that agencies review the use of wound care supplies and keep careful track of their inventories.
First, she says, an agency should standardize its inventory to ensure that staff are using the best products available, and that supply shelves aren’t groaning with rarely used products ordered for one patient or one physician.
"You don’t need three transparent films. You need one good one," she says. "You don’t need 10 different hydrocolloid dressings, you need one. So when a physician calls and says, I want you to use Brand X,’ you can say, We have Brand Y hydrocolloid dressing, and this is what we use.’"
If the agency doesn’t have a designated wound nurse who can conduct this review, Baranoski says it would be worth contracting with an outside WOCN nurse to do so.
The goal isn’t necessarily to find the cheapest supplies available, but those that are best suited to your nurses, patients, and their family caregivers, she says.
"I think it would be a big mistake to go out and buy the cheapest barrier ointment instead of one that you know has worked well and you’ve had good success with," she says. "I think it’s a big mistake to downsize to an inferior product, because in the long run, the patient’s not going to heal as well, and you may end up being in there longer because of complications that could occur."
An agency has to look at its own practice patterns, the success it has had with various products, and what its physicians are most comfortable with.
Baranoski advises putting together a wound care list or formulary and distributing it to physicians. If they ask to add to the list, the agency can evaluate the suggested product.
"The care of the patient shouldn’t be based on the cost of the product at all," she says. "If the patient needs an expensive product and that’s what the physician has deemed is the best avenue for that patient, then that’s what we need to provide. But what’s needed along with the products is good wound care, wound assessment, documentation, and follow-up."
Bottom line, says Baranoski, "Products don’t heal wound care patients; good wound care heals patients’ wounds."
In addition to reviewing the list of supplies, Silver Cross upgraded its supply closet to a computerized system that keeps better track of how the products are used.
Previously, when a nurse went to the closet to get a product, she could simply take out what the patient needed and make a notation on the patient’s billing.
Invariably, that led to problems keeping track of items. "You had people who took extras, because maybe they were going to need it," Baranoski says. "[The products] would freeze up in the trunk of their car in the winter, or maybe it’s 98° out and it melted. So the product got ruined. It wasn’t being billed to anybody, but you were still paying for it."
Now, in order to remove items from the cabinet, a nurse must punch in his or her ID code, as well as the patient’s name.
"At the end of a day, we know where the products went, we know who took them out, and we know which patients have them," she says. "It has decreased our costs immensely because we don’t have the waste of products."
Although the agency no longer can bill the patient, keeping track of what products a patient uses can help gauge the effectiveness of different wound care products, Baranoski says.
Keeping detailed records of patients’ supplies also will come in handy if supplies are eventually unbundled from the episodic payment and agencies can begin billing for them again.
Other tips for effective wound care
Baranoski offers other suggestions for improving wound care while adjusting to the demands of PPS:
• Promote a multidisciplinary approach. At Silver Cross, case conferences on wound care can involve nurses, physicians, physical therapists, dietitians, and social workers.
Physical therapists don’t do wound care themselves, but work to get the patient out of bed and moving around to improve circulation. The agency contracts with a dietitian who reviews charts to ensure that patients are getting needed nutrition for healing. Social workers help with other issues that might impair a positive outcome and refer patients to community services that might help them after discharge.
"If agencies aren’t doing case conferencing with a multidisciplinary team approach, they’re going to fall behind," Baranoski says. "They have to look at involving all the disciplines in wound care. That certainly includes the physicians."
• Prevention is key. "If you’re not looking at preventing the wound care insults that can occur from immobility and your various diagnoses, your patients are going to develop all kinds of wound care problems that are going to keep you in there much longer and cost you a lot of money to manage," she says.
Silver Cross uses a risk-assessment tool and nutritional screening to determine high risks for wound problems. Patients are taught the importance of ambulation, nutrition, and other approaches to avoid wounds.
• Be sure staff is up to date on documentation. Baranoski has quizzed her staff on all the documentation required by PPS, including Outcome and Assessment Information Set (OASIS) assessments. She notes that one good thing to come out of the final PPS rule was some case mix adjustment for complex cases including wound care. But that requires proper documentation.
"Having the right documentation tools is very important," she says. "Are you using an outdated computer system that doesn’t have some of the things you need? We all have to transmit OASIS data, but you also need your other documentation that supports what are you doing."
Baranoski says it’s too soon to see how PPS will affect wound care in the long run. "It’s going to be interesting to see how wound care evolves through the use of all the documentation through OASIS," she says. Ultimately, though, she says agencies will have to continue to monitor their standards and adapt as necessary. "Constantly evaluating on an ongoing basis ways that you can improve and enhance your practice is something we all need to be doing," Baranoski says.
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