Developing Smart Wound Care Practices

The Medicare prospective payment system for skilled nursing facilities (SNF) and home health agencies (HHA) has had a significant impact on the delivery of wound care services. If your customers include these service providers, your best bet is to help them practice smart wound care. This means finding profitable solutions that will not compromise quality of care.

The bottom line: Success under PPS is possible only if SNFs and HHAs analyze their specific wound care patient mix and develop strategies that translate into smart wound care practices. Provide consumers with the tools they need and you guarantee their success. If they know their costs and achieve positive healing and cost outcomes, your business will flourish as well.

Here's what they must do.

Analyze the Wound Care Patient Mix

Analyzing the wound care patient mix includes: identifying the population by type and acuity level; determining costs required to achieve timed outcomes for each wound type; and pinpointing minimum data set (MDS) and outcomes and assessment information set (OASIS) items that impact reimbursement.

Some basic information is required to analyze the wound care patient mix. Specific wound data may be difficult to access, but the wound care specialist or nursing supervisors can identify patients by wound type and then classify them by low or high acuity.

Success under PPS is possible only if SNFs and HHAs analyze their specific wound care patient mix and develop strategies that translate into smart wound care practices.

First, the wound care specialists should determine what percentage of SNF admissions or HHA visits are wound-care oriented. Next, they must classify these patients by wound type: pressure ulcer, diabetic ulcer, venous stasis, infected/non-healing surgical wound or arterial ulcer. Last, the specialists should breakdown each wound category by percentage acuity level. Are the wounds mostly low severity--usually only require a minimal number of visits to complete the plan of care--including non-complex pressure ulcers, such as Stage II, clean granulating wounds; healing surgical wounds? Or are they high severity--wounds covered with eschar or necrotic tissue; infected and draining surgical wounds; venous stasis ulcers of long duration; non-healing diabetic ulcers?

Once a SNF or HHA has defined its wound care population, staff must determine the total cost to achieve timed outcomes for each wound type. This includes calculating the total cost from admission to discharge for the different types of wound care patients. Applicable costs for specific wound type include skilled and non-skilled services, supplies, durable medical equipment and adjunctive treatments.

First, the SNF or HHA professional must ascertain the average length of stay or usual number of visits for each specific category. Skilled services or visits made for wound care should be differentiated from physical therapy and other providers.

Wound care is a complex specialty area that requires constant monitoring and an enormous amount of education.

The next step is to identify the usual outcome at discharge for the specific wound care population. A wound care outcome is a picture of the destination of the patient, and it allows a provider to evaluate interventions and their effect on the patient's progress. The results of all care interventions should be measured against specific achieved outcomes. For wound care, these outcomes may include shorter length of stay, reduced nursing time, fewer agency visits, faster wound healing, decreased incidence of complications and lower total supply costs.

Wound-specific outcomes should direct the plan of care and determine the time to discharge. For example, a HHA may choose to discharge a patient with a Stage III pressure ulcer after the wound size has decreased by 50 percent if the responsible caregiver demonstrates consistent wound care.

Finally, SNF and HHA associates must evaluate key MDS and OASIS assessment questions that will impact reimbursement. They must then examine a typical wound care patient and combine the data with assessment and documentation items to find potential problem areas. Then the personnel can determine the financial impact, based on the payment potential under a specific RUG or HHRG. By defining current case mix and resource use, then comparing these with expected reimbursement under PPS, a provider can identify problem areas.

Practice Smart Wound Care

After completing the wound care patient mix analysis, the next--and most essential step--is to use treatment approaches that promote healing and control the cost of wound care. Critical interventions should focus on resource utilization and clinician education.

Maximize Resource Utilization

Using specialists to ensure appropriate admissions, develop effective treatment plans and control supply costs is a smart move. Initially, SNFs and HHAs tried to cut costs by using cheaper supplies or eliminating the use of outside consultants. However, a wound care expert can help them understand supply cost and facilitate appropriate utilization.

Following critical pathways is one way to develop a data set that compares outcomes among wound care patients treated by a SNF or HHA. Critical pathways, also known as care maps, are created through collaborative practice, based on standards of care. As a result, they help health care professionals implement specific interventions and anticipate expected patient responses. For example, if a patient has a wound, the care map guides the clinical team on treatment approaches that achieve measurable outcomes, such as debridement, presence of granulation tissue or wound closure.

Wound treatment modalities must be defined based on wound assessment. Characteristics of the wound dictate a management technique, as opposed to habit or physician preference based on unproved or potentially harmful treatment modalities. Critical paths will ensure quality care based on the current standard of practice.

Wound care is a complex specialty area that requires constant monitoring and an enormous amount of education. Hundreds of new products and treatment modalities are introduced each year. Without up-to-date clinical data and first-hand knowledge of which wound conditions are likely to respond to specific interventions, product use can easily cost more than a SNF or HHA will receive under PPS. Consequently, controlling supply costs and utilization is essential to survive under PPS. Rather than eliminating treatments, equipment and supplies, careful inventory control and staff education are smarter solutions.

It is important to differentiate pressure ulcers from other types of skin lesions.

Although cost control is essential, clinicians still need access to products and therapies that yield positive outcomes. Using wound care specialists to identify products in stock that are rarely used is a smart decision. So is including these specialists on the supply committee to evaluate new products and determine appropriate use parameters. They can recommend one or two manufacturers or suppliers with a full product line or select specific product lines for the wound types identified in the patient mix analysis.

A wound care expert also can develop a formulary and product use chart that will guide nurses on which dressings are suitable for specific wound characteristics. Unit cost, usage and outcomes by product category must all be evaluated. For example, is it better to use a more expensive product that does a better job so nursing visits are decreased or to use a cheaper product that results in more frequent nursing visits?

Enhance Clinical Education

Ongoing internal education and training on wound care is critical for appropriate documentation and, ultimately, reimbursement. All health care professionals must learn how to appropriately assess wounds according to stage and other characteristics found in MDS and OASIS items. They should be well-versed in the definitions, specific instructions and assessment strategies contained in the implementation manuals. For example, it is important to differentiate pressure ulcers from other types of skin lesions. Many nurses still do not understand that it is incorrect to reverse stage granulating pressure ulcers.

The wound care specialist can demonstrate photo examples of patient wounds and how to document the corresponding items. Then, comparing staff responses will pinpoint common documentation errors that correlate to loss of payment. Based on clinical data, a wound clinician can determine reasonable timeframes for signs of wound healing, such as change in size and the quality of the wound bed. Nurses need to know that long-term wound care without reassessment at appropriate time intervals is inappropriate. Experts also can teach staff about wound etiologies and comorbidities that are likely to impede the healing process. A non-healing wound may be an indicator of undiagnosed diabetes, malnutrition or other unknown disease processes.

Develop a Strategic Plan

The final goal for treating wound care patients under PPS is to achieve financially viable positive outcomes. Here are a few key strategies to employ:

  • Define the expected outcome. Is it obtainable and measurable? Does the entire treatment team agree on the expected outcome?
  • Develop specific treatment interventions based on care maps and benchmarks.
  • Educate all personnel on specific treatment interventions and timed outcomes to discharge.
  • Identify critical resources including dressings, adjunctive therapies and specialty consultants.
  • Weigh the unit cost of supplies or treatments against visit use and total costs to reach the desired outcome.
  • Incorporate the current standard of care to ensure quality and eliminate inappropriate physician orders.
  • Use documentation tools that will demonstrate that desired outcomes are achieved.
  • Track outcomes; collaborate among care disciplines and document the results.
  • Know the true cost of delivering wound care.
  • Evaluate cost issues and cost effectiveness of the interventions.
  • Document MDS and OASIS accurately and completely to support payment.
  • To obtain guidelines for wound documentation, standardized documentation formats, wound documentation examples, sample forms and other valuable resources, send a check for $79.95 (includes shipping) for the publication Defensive Wound Management, co-authored by Glenda Motta. Make checks payable to Pathways to Empowerment, 12300 Prospect Landing, Mitchellville, MD 20721.
  • This article originally appeared in the September 2001 issue of HME Business.

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