by Dennise Derby-Bemis

It is virtually impossible to discuss wound care within the long-term care environment without paying heed to payment, regulatory, and legal issues.

Wound care is a hot topic within the industry because of concerns about quality and cost, as well as concerns of payers, legislators, regulators, consumers, and attorneys. We are all aware of the recent TV and radio commercials that start with, "Do you have a loved one in a nursing home?”

Revisiting wound care practices

Quality and cost concerns are forcing providers to evaluate their wound care practices.

Under previous cost-based reimbursement systems, long-term care providers (skilled nursing facilities and home health) were paid to treat wounds regardless of the outcome of the care. Today, providers are being held accountable clinically and financially to heal wounds, follow accepted practice guidelines, and maintain accepted regulatory standards.

With limited reimbursement under PPS and Medicaid, providers must be more fiscally smart, while still providing high-quality care for not only regulatory and legal standards, but marketability.

F tags and state deficiencies have increased each year, with pressure ulcers listed directly or indirectly in 80% of the most common deficiencies. A recent Statement of the Deputy Inspector General of the U.S. Department of Health and Human Services stated that 78% of nursing homes received at least one deficiency in three categories related to quality of care.

Resident assessments and the Minimum Data Set

Of particular concern was the category that showed the greatest overall increase—resident assessments. Resident assessments are required to be conducted by an interdisciplinary team comprised of nursing home staff when individuals first enter the skilled nursing facility (SNF) and at other prescribed intervals.

The Minimum Data Set (MDS) is a comprehensive assessment tool for nursing home residents and is used for clinical decision making, research, quality improvement, and Medicare and Medicaid reimbursement. The MDS is the instrument utilized for routine assessments and may trigger additional, more specific assessment protocols, depending on clinical and functional conditions observed.

Such protocols, in turn, provide the framework for developing care plans to address the needs of the residents. In 2005, 50.1% of nursing homes had at least one state and/or federal deficiency related to resident assessments.

In addition, the MDS is now used not only to conduct patient assessments, but also to help facilities measure and adjust patient outcomes and connect payment with the utilization of the required resources via resource utilization groups (RUGs). These RUGs are the payment mechanisms for both state- and federally-funded patients. HCFA and state regulators also now have the ability to link correlating data, such as the development of a pressure sore.

Raising the bar with more aggressive wound care

SNFs should consider adding wound care to their repertoire as RUGs pay more per patient for wound care treatment.

This sounds like an impossible task, but in truth, we can't afford not to. Long-term care providers must pay all costs for healing wounds under Medicare Part A (PPS) and will likely find it difficult to bill for and receive payment for wound care under Medicare Part B, which would be the payer of a Medicaid patient's wound care costs.

In addition, it will enhance our industry to ensure our nursing staff "raise the bar" and accept the challenge of taking care of more complex patients. Aggressive wound care is often more cost effective in the long run if the wound is extremely large, difficult to heal, or not progressing. More expensive, aggressive therapies can actually be more cost effective if the results are shorter healing time and less "hands on" nursing staff time.

Healing rates and the resource utilization should drive the cost effectiveness of wound care. Any technology that changes the wound environment to facilitate shorter healing time should be considered in the resident's care plan, not to mention the regulatory, legal, and marketing advantages to successful wound care programs.

Interdisciplinary wound care teams

Unfortunately, most facilities have no idea what it costs to provide wound care or the differences in their costs for caring for a Stage II or a Stage IV pressure ulcer or other stasis ulcers. (By the way, in 2005, the average cost for healing a Stage IV ulcer was $37,000.)

Facilities must take steps to develop interdisciplinary wound care teams, establish admission criteria, and set up wound care protocols. These criteria should enable facilities to deliver quality care below the PPS payment level and still adhere to regulatory and payer requirements.

The expertise of wound care specialists (wound-care-certified health care providers) and other important members of the wound care team, such as dietitians, physical therapists, and other vested members of the interdisciplinary team, should be consulted to provide intense, up-front care to speed up and enhance healing.

The efficacy and cost effectiveness of an in-house, interdisciplinary wound and skin care team has been clearly documented and is the key in regulatory compliance. Monitoring, tracking, documenting, and care planning treatment will go a long way in preventing legal issues and state deficiency fines.

Wound care products and treatments

Facilities should also establish the utilization criteria for "cost-effective" wound care products, such as dressings, ointments, and specialty beds, and should ensure the plan of care clearly reflects current practice standards.

Formularies of wound care supplies should be correlated with clinical pathways that become the cost descriptors for specific types of wounds. A $400 tube of collagnase debriding ointment is not always the most cost-effective or quality method of treatment. Certain products do perform better than others, but it is important to use products properly. If wounds do not respond to treatment within two to four weeks, reassessment and changes in the plan of care must be initiated and documented.

Physicians must also become more familiar and involved with the wound care team and become familiar with up-to-date treatment modalities. Some physicians are still giving nursing staff orders for "wet to dry" dressings, which were stopped in the 1980s! In addition, if the facility obtains a physician's endorsement of the facility's wound care formulary, it can save significant dollars.

The interdisciplinary wound care team should meet and develop a strategy for wound care team survival. The team should pay particular attention to supply purchases and the utilization history of wound care supplies.

• Determine actual utilization, brands, duplications, and costs.
• Review your supply contract with vendor(s) for terms, length of contract, and services provided.
  • Develop a simple, staff-friendly system for ordering supplies.
  • Review delivery options and costs.
  • Review space available for inventory. Avoid large inventories because of changes in clinical practice and supplies becoming obsolete and outdated.
  • Review inventory management options.
  • Review and insist on rapid turnaround time.
  • Make sure costs are competitive and the vendor has a reasonable and simple return policy.
  • Ensure there is a timely and efficient system for order and delivery confirmation.
  • Ensure there is coverage for "off shift" and weekends. Insist on a knowledgeable and accessible account representative assigned to your facility.
  • Make sure you receive weekly invoices that can be customized to your needs, including patient-specific supply listings and sorts by payer and costs.
  • Review Part B billing options.
  • Ensure there is expertise to assist the team in development of a product formulary specific to your facility that will improve your bottom line.

• Assess rationale for product duplications and make sure units of measure are appropriate. 
• Analyze costs and alternatives.
• Make sure you retain quality products in your inventory/formulary. Cheaper products are not always cost effective.
• Evaluate unit cost, usage, and outcomes by product category. For example, is it better to use a more expensive product that does a better job so nursing time is decreased than to use a cheaper product that results in more frequent nursing treatments? Some dressings need to be changed weekly, as opposed to daily or several times a day.
• Develop critical paths to decrease time and achieve positive outcomes quickly.
• Develop a formulary and product use chart that will guide nurses on which dressings are suitable for specific wound characteristics.
• Take your formulary revisions to your vendor and work with them for their best prices. Ask for their ideas on cost containment specific to your facility.
• Compare prices with those of other vendors, and negotiate.
  

Communicating the new strategy

After developing a comprehensive wound care strategy, the key to financial success is communication to your staff. In-service education on how to use products will "pay it forward" for cost savings and quality outcomes.

Teach your staff "more" ointment is not always better and about proper dressing application techniques. Educate staff that they are not taping a mummy! When you communicate your goals to and educate the entire staff, they will be more likely to "buy in" to your ideas.

Develop and validate your staff's capabilities, and empower them to serve on the wound team, as well as develop a wound care policy.

It has been shown 50% of staff that are dissatisfied complain they are not kept up to date on and informed of new procedures and policies. An informed staff is a happier staff. Be flexible, be prepared to modify your formularies as new products become available and your staff offers suggestions, and keep in touch with vendors and utilize their expertise.

Wound care can become a "plum" for your facility, especially the nursing department. Take some time to consider the financial opportunities and advantages of adding these services.

Additional information

If you have questions or would like additional information, please contact Dennise Derby-Bemis at dderby@wipfli.com or 414.431.9332, or visit www.wipfli.com/healthcare.