Make it a goal this year to improve wound care outcomes, costs, referrals
Key to success is changing product formulary
Home care agencies are in a good position to improve their wound care treatment and enhance referral base by moving into the 21st century with new wound care products and protocols.
"We have gone to great lengths to develop a very advanced wound care program," says Michelle Mullins, RN, BSN, manager of clinical operations for the Alexian Brothers Medical Center Home Health Department in Hanover Park, IL.
"The benefits have been that it has allowed us to control our costs, provide consistent quality care to patients, and have good outcomes," Mullins says. "That’s the No. 1 one thing people are looking for with the prospective payment system [PPS]."
Since last May when the agency redesigned its wound care product formulary and treatment guidelines, the agency’s wound patients have been healing much faster, Mullins says. While this always is the primary objective, it also helps that the improvement has helped the agency’s bottom line under PPS reimbursement.
"We’re using advanced wound care techniques, and the new products are helping us drive down the number of visits required to accomplish our goals," Mullins explains.
"These are products that everyone has the capability of using in home health," she adds. "It’s just a matter of to what extent you’ve gone to assess what’s out there and to look at your wound formulary."
Here’s how Alexian Brothers’ home health agency made those changes:
1. Redesign wound care formulary.
The goal is to find wound care products that will improve wound healing times and maintain safety. Health care manufacturers have developed a wide variety of products that do just that. New technology also makes it easier for clinicians to evaluate a wound. A committee looked at the available products and selected a vendor.
Then home health managers met with clinicians to decide which products to use and place on the new formulary. "We looked at what was already on there and what we could get rid of; and what new stuff to adapt, make uniform, and go from there," Mullins says.
The agency then developed the formulary and wound care treatment guidelines, using the vendor’s product information. (See wound care guidelines, right.)
For example, the home care agency has begun to use a digital camera that when used in conjunction with a computerized wound care program can track a patient’s wound healing progress.
When a nurse visits the patient, he or she can take a picture of the wound and use that image to consult with a wound care specialist. The specialist will oversee the wound care and make sure field staff use the best products for that particular type of wound.
The digital images of the wound also can be used to offer visual documentation on the chart. "This is great for state surveys, for physicians, and for payers," Mullins says.
"Some physicians like these so much, they say, If I have so clear a picture of what the wound looks like, I won’t have to provide so many follow-up visits,’" she says. "So we can save a cardiac surgeon an office visit because their follow-up visits are part of the surgery package."
Seeing this as a clear benefit, physicians are more likely to refer patients to the agency for home care treatment.
The Alexian Brothers agency also has used those digital images during surveys by the Joint Commission on Accreditation of Healthcare Organizations of Oakbrook Terrace, IL. "The Joint Commission really likes it because it shows a clear picture and tells a story in the chart about what is happening with a patient," Mullins notes. "They can see the patient’s progress; it’s a great documentation tool."
The images can be sent to payers and physicians by e-mail or fax. New technology also has resulted in products that can be substituted for the "wet-to-dry" method of wound healing. One such product is a Hydrogel-impregnated gauze dressing that promotes moist wound healing. Another one is an absorbing gel called Iodosorb, which can absorb the drainage and minimize the bacterial load when applied into the wound bed. This product also reduces wound odor and will change color to indicate that it’s time to apply a new dressing.
2. Train staff how to use new products.
The agency created a new position called the certified wound care specialist, a clinician who attended additional courses on wound care and received certification. The specialist’s role is to consult with other field staff on wound care treatment, answering their questions when problems arise.
The wound care product vendor provided educational material that was used in giving staff inservices on the new treatment protocols.
3. Develop wound care grid.
The wound care grid has detailed pictures of different types of wounds. With each wound description, there are lists of products and procedures on how to handle that particular type of wound.
This provides staff with a uniform and illustrated example of how to best provide wound care in any given situation.
For example, the wound care grid for a cavity wound shows two photo examples of stage IV wounds, offering a definition that says, "Full-thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures (i.e., tendon, joint capsule). Then it lists the following information:
• Treatment C — minimal exudate to no exudate
1) Cleanse area with saline or Dermal Wound Cleanser. Pat skin dry.
2) Apply 3M No-Sting Wipe. Allow to dry thoroughly.
3) Fluff SoloSite Conformable Dressing into wound. Be sure to lightly pack tunneled areas.
4) Cover with appropriate Tegaderm or CovRSite.
5) Change dressing Q 1-3 days or PRN.
6) Discontinue treatment when wound characteristics change or when area is healed.
• Treatment D — moderate to heavy exudate
1) Cleanse area with saline or Dermal Wound Cleanser. Pat skin dry.
2) Apply 3M No-Sting Wipe. Allow to dry thoroughly.
For granulating/clean wound beds:
• Place AlgiSite M in wound. Be sure to lightly pack tunneled areas.
• Cover with Allevyn or Allevyn Adhesive Dressing.
3) Change dressing as appropriate
• OR debride enzymatically.
4) Discontinue treatment when wound characteristics change or when area is healed.
Such involved details leave little guesswork in wound treatment and ensure a greater consistency in care, Mullins says.
"This way there is not much variance in how each clinician handles a wound," Mullins says. "This has seriously helped us, and it’s one of the contributing factors to decreasing our costs."
4. Educate physicians, other referral sources.
The agency’s wound care specialists meet with physicians who are reluctant to prescribe new products. The specialists give them a history on the new products and explain how using these have helped improve wound healing times and reduce complications. "When we get referrals of patients who have wound infections, we meet with the physicians and educate them on the wound care products," Mullins says.
The home care agency also has been working closely with cardiac surgeons to obtain more patient referrals. Many physicians are also under reimbursement constraints, and they understand how PPS has changed the home care industry. "With PPS, the name of the game is to fix the stuff early on," Mullins says. "You can do it right away to limit the number of visits, providing the appropriate amount of care but doing what you can to control costs."
• Kathy Kelly, RN, Quality Improvement Manager, Norrell Health Care, 3535 Piedmont Road N.E., 12-C, Atlanta, GA 30305, or 350 Northern Blvd., Suite 108, Albany, NY 12204. Phone: (518) 434-1657. Fax: (518) 434-1677.
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