Diabetes and Wound Care:

Knowledge Is Power

By fostering a free flow of information between referral partners and patients, HME providers can help ensure prevention and treatment of foot wounds.

Diabetes is running rampant in the United States. If you have any doubts regarding that, consider these two statistics from the American Diabetes Association: First, 8 percent of the U.S. population, or 23.6 million people, have either Type 1 or Type 2 diabetes. Second, diabetes accounts for more than 60 percent of non-traumatic lower-limb amputations. In fact, the rate of amputation for diabetes patients is 10 times higher than it is for people without the condition.

This is due to complications that beset diabetes sufferers, such as vascular disease and neuropathies. Diabetes patients suffer a variety of complications ranging from heart disease, kidney disease, skin disorders, and eye problems, including blindness, but complications related to their feet are both prevalent, and an instance where HME providers can greatly aid diabetes patients.

 “The most obvious [complication] and the one that comes to mind first are things related to the feet,” says Martha Funnell, MS, RN, CDE, who works at the University of Michigan’s Diabetes Research and Training Center. “People with diabetes and neuropathy are vulnerable to foot care issues and wound issues related to injuries or trauma from shoes — and they can be devastating if not treated promptly.”

Neuropathy is a nerve disorder in which nerves basically stop functioning like they should. Approximately 60 percent to 70 percent of diabetic patients can develop some form of neuropathy somewhere in their body, with the highest risk group being those who have had the disease for 25 years or more, and those who do not do maintain the right blood glucose levels.

Neuropathy symptoms can include a tingling sensations or numbness, and when it comes to the feet, numbness can quickly becomes a serious problem. If the foot is numb, and unobserved blister can quickly grow into a serious ulcer if left untreated. As a result, even minor issues should warrant strong concern, because of the chance that they could get much worse, says Funnel, who also is a member of the American Diabetes Association’s professional practice committee.

“Ultimately, those are the main causes of amputations,” Funnell says. “Diabetes is the main cause for non traumatic amputations in this country, and many of those could be treated with appropriate wound care.

“I think the key is very prompt initial response to any kind of wound that happens to your feet in particular,” she continues. “Obviously, there are issues that people can handle themselves versus seeing a professional.

Thinking on Your Feet

Diabetes patients with neuropathies essentially lack the warning system that nerves provide in letting a person know that their feet hurt because their shoes don’t fit.

“It’s thought that shoes are the greatest source of trauma to your feet,” Funnell says. “For the most part it’s related to poorly fitting shoes. The days when you went to the shoe store and they actually fit the shoe to your feet with multiple widths in the toe and in the heel are gone, and shoes are sort of mass produced.

“Choosing well-fitting shoes that protect your feet and that are appropriate for the situation is critical from a patient education perspective,” she continues. “It doesn’t mean you can never wear high heels or sandals or nice shoes, it just means that if you’re walking five miles, those probably aren’t the shoes you want to wear. It’s using some common sense and thinking for your feet in the way your nerves used to.”

So the patient has to do the thinking for their feet, instead. They need to ensure they have the right shoes, and they need to closely inspect their feet when they take off their shoes to ensure there are no red areas or blistered areas or sores. Special diabetes footwear can help.

“In general diabetes footwear is recommended for patients with neuropathy and certain foot problems,” Funnell says. “Once that happens, it becomes a covered benefit, and patients hopefully are then referred to a podiatrist or orthotist, a person who specializes in making orthotics and shoes.”

Grace Under Pressure

In addition to diabetes foot wear, the other key aspect of HME involved in caring for diabetes patients with wound care issues is compression, says Claudia Boyle, owner of Van Driel Medical Specialties in Mount Prospect, Ill. Van Driel Medical specializes in compression.

“We do almost exclusively compression wear,” she says. “We do some soft orthopedic goods, but 90 percent of what we do is compression wear. So we’re kind of unique facility in that aspect. Our two biggest sources are wound care clinics and lymphedema clinics.”

Compression can play a key role in the treatment, maintenance and healing of wounds. Compression allows oxygen from the circulatory system to better penetrate into the tissues. Without compression, fluid builds up in the tissue which prevents oxygen and nutrients from penetrating the skin effectively and causes skin breakdown.

“When compression is applied, it acts like a little ‘anti-gravity sock,’” Boyle says. “It supports that circulation back up out of the limb, the skin is better supported, and the whole health of the leg is improved by providing the right amount of compression.”

Typically, diabetes patients come to HME providers for their compression needs after they have seen a wound care treatment specialist, and now must care for the wound. This is where a provider with a good level of compression expertise can delivery considerable value and expertise.

“What usually happens is that [patients] are coming out of wound care and they’ve been getting some kind of compression wrapping, and they’re coming for compression wear as they become more healed and go into a maintenance phase,” Boyle says. “That transitional phase from healing to maintenance is usually where we get brought into the program.

“For all the wound care patients, we have to consider the appropriate amount of compression and limitations, the shape of the leg … and we also have to toss in the fact that there might be some compromised arterial issues that we have to be aware of,” she continues. “So we have to be extra careful not to over compress the leg.”

Additional factors in providing compression to diabetic patients could be whether or not the garment needs to be open toe because there are issues on the toes, or closed toe, because there are issues at the base of the foot, which would not be a good place to end the stocking, Boyle adds.

Working with diabetes patients for their compression needs, Boyle says the key for the provider is to take some time with each individual, and intently listen to what their needs are.

“Talk to them and listen to them about their concerns, about their limitations,” she says. “Do they have help with their compression garments, or will they have to put them on themselves.”

The provider must then create a program that fits patients’ individual needs and limitations. Both variables must be considered in order to ensure the patient sticks with his or her compression treatment. Compliance and positive outcomes require a careful balance.

“There isn’t just one thing that works for everybody,” Boyle explains. “There is a lot on the market now, and not a one of them is perfect for everybody. So you really have to try to work with [patients] and their therapist to find what they’re really willing to do. What will this patient really wear every single day and manage every single day?

“We can send them home with the greatest compression garment in the world, but if they’re not putting it on, it has zero value,” Boyle continues. “So, how much do we need to make allowances for backing off the compression to make things more manageable for [patients], and still have a result that we want.”

A tight relationship with wound care referral sources is key in fostering that compliance by ensuring that the compression stocking is properly sized. This can be tricky when the patient is just coming out of wound care, Boyle says.

The difficulty in transitioning a patient from wound care to compression therapy is that, during wound care, the legs can be squeezed a good deal from compression wrappings, so the provider must work with therapists, wound care providers and physicians to know when the patient can be measured for the stocking in order to ensure it will remain a good fit for them (while still maintaining the goals of the therapist). Too early, and the stocking could be too small or too high a compression.

In terms of funding for compression when it comes to diabetes patients and compression, this is the one instance where Medicare will fund a compression garment.

“With an open stasis ulcer diagnosis, that is the one time Medicare will actually provide a stocking,” Boyle says. “It has to be at least 30 to 40 millimeters of compression, and sometimes for diabetics that’s too much, which takes them out of qualification.

“It has to be used with a liner sock,” she continues. “It gets covered as a two-part compression system to hold the dressing. It has to be used to hold a dressing. Under those circumstances Medicare will then reimburse.”

While funding is ideal, ensuring optimal compression is critical. Diabetes patients can have arterial deteriorations, and if too much compression is used, blood might not properly circulate in the leg; a serious issue. “So we have to be cautious,” Boyle advises.

Getting a compression fitter certification from mainly vendor courses or possibly via an enhancement to an orthopedic technologists certification, can be helpful, but ultimately it comes down to product knowledge and problem solving, Boyle says.

“You have to know everything that is out there, so that you can make a good decision,” she explains. “It’s more about product knowledge and a willingness to tailor the program to the patient, than it is credentials.”

In terms of new developments in compression products, Boyle says a number of products have been released over the last two years that include hook-and-loop straps to make putting on and taking off the compression garment much easier to put and take off, which can be tricky using the standard methods (see “Donning and Doffing Compression Garments”).

“It’s easier to fit because you have an adjustability of sizing,” Boyle says. “The straps are not as limited in sizing, as the socks, which have a very small — centimeters — of range. These have inches of range on some of them. So if patients can bend reasonably well to their ankle, and strength is an issue, the Velcro straps can be lovely and can accommodate the normal fluctuations in sizing. So it’s often a good choice.”

Exchanging Ideas

Besides sharing their expertise with specific HME products, such as compression or shoes, providers could be a key link in ensuring better treatment for patients by serving as an information clearing house, or, better yet, a catalyst for better communication between all the parties involved in diabetes patients’ care.

If there’s any doubt that patients aren’t getting all the information needed, Funnel points to footwear recommended for patients with neuropathy and foot problems: “Many patients don’t know that is a benefit that is covered by Medicare and many insurance policies,” she says.

That lack of knowledge regarding coverage, points to a larger information deficit at hand in the diabetes and wound care communities: a need to share information. And this could be a place where providers can help in the treatment of diabetes patients’ foot complications.

Just looking at wound care, there are various treatments for diabetes-related wounds. Wound care treatment is not uniform, and approaches to treatment can vary from expert to expert. HME providers work with a variety of experts who evaluate and make wound treatment recommendations. The key is to establish a good dialog with wound care centers to learn the types of treatments they prefer and determine how the HME business can help spread that information, UMI’s Funnell says.

“That’s part of the training that needs to occur in order for us to better relay those message to patients and to make sure that patients get those appropriate treatments,” she says. “Clearly there are things that can be done early that can prevent those very serious consequences.”

Funnell says that diabetes caregivers could gain more knowledge in terms of wound care, as well as develop closer relationships with wound care providers and podiatrists, as well. This is an area where HME providers could again foster an exchange of information between the diabetes and wound care worlds, both patients and physicians, she says.

“That’s a gap right now, and it’s a problem,” Funnell explains. “Obviously, there are a variety of wound care providers and therapies, many of them very effective, but it’s like diabetes: the diabetes knowledge tends to stay within the diabetes community, just like the wound care knowledge tends to stay within the wound care specialty area, and we don’t tend to cross train.

“I think there’s a real important role for home medical companies and even pharmacies that are expert in this area, to provide continuing education,” she continues. “Perhaps training on both sides would be helpful. A cross-pollination of ideas at a professional level eventually leads to better patient outcomes.”

An information exchange could result in better prevention of diabetes-related wounds, as well as better treatment at an earlier stage, which is critical from a patient perspective. The key is to get started.

“I think the first thing is to make patients aware of the need for early intervention; that you just don’t ignore something on your feet and hope it gets better,” Funnell says. “If it is not getting better with what [the patient] is doing within 24 to 48 hours — if it’s not starting to heal — getting to someone who can help you, whether it’s a diabetes educator or your primary care physician or your podiatrist or a wound care expert, [the patient] needs to jump on that and be very aggressive in the treatment.”

Again, the provider can be the springboard for the referral. Also, like compression, having credentials on staff can help, but isn’t entirely necessary toward promoting this education.

“I think it depends on their focus,” Funnell says. “Many HME providers will specialize in a particular area, so having a diabetes educator available on staff or as a referral source can be very helpful. If your main thing is orthotics and wound care, then having access to a wound care specialist is helpful. So it really depends on the HME and what their targeted patient population is.”

Bottom line, HME providers should strive to develop directories of referral partners to which they can direct patients. By functioning as an intermediary or “matchmaker” between these key players, the provider can deliver a huge benefit to patients.

“We have HME companies in Michigan that do continuing education programs both for patients and professionals in physicians’ offices,” Funnell says. “That’s so important, because diabetes people tend to go to diabetes meetings, and wound care people tend to go to wound care meetings. Trying to link those two groups would be beneficial for the patients, but also beneficial for [the HME provider] in terms of their referral process and their business model.”


Points to Take Away

•  Diabetes affects more than 8 percent of the U.S. population and accounts for the majority of non-traumatic lower limb amputations.

•  This is due to neuropathy and other complications that make it difficult for patients to realize they have foot sores, and for those sores to heal.

•  These sores can quickly grow into ulcers. The key to prevention is quick detection and treatment.

•  HME such as diabetic shoes can help prevent foot problems, and compression garments can help heal those problems.

•  Perhaps one of the best ways HME providers can assist in the treatment is through fostering communication and education between all parties involved in the diabetic patient’s continuum of care.

•  Acting as a key intermediary between these parties also could benefit the HME provider’s referral business.


Learn More

The American Diabetes Association provides a wealth of information on diabetes and diabetes care that is specifically tailored to healthcare providers. Visit the DiabetesPro web site at professional.diabetes.org to find various information resources that HME providers can leverage to help create a better exchange of information between patients and all the referral sources involved in their diabetes treatment and wound care. This includes not only a continuing education library, but patient education resources, as well.


This article originally appeared in the August 2009 issue of HME Business.


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