Better Skin Care Under PPS.

One of the many ways that skilled nursing facilities (SNFs) can lose money under the Medicare Prospective Payment System (PPS) involves skin and wound care. A resident turns up with a stage 3 or 4 pressure ulcer, for example; the SNF staff treat it with high-tech dressings, support surfaces and intensive nursing care, but for some reason Medicare's reimbursement is nowhere near the costs incurred. It doesn't take long for this to add up to serious financial losses. Thus, the SNF faces a dilemma: Either cut costs and put residents and the facility at risk for clinical mismanagement, or try to find a better way to approach skin care and enough money to support it.

For the past 10 years Gwen B. Turnbull, RN, CETN, has been a sort of "roving ambassador" for better skin/wound care practices, lecturing and consulting with healthcare facilities throughout the United States, Western Europe and the Far East. Most recently she has been focusing upon educating SNFs and home health agencies to cope with the risks and complexities of PPS. Recently Nursing Homes/Long Term Care Management Editor Richard L. Peck asked Ms. Turnbull to distill some of the advice she is passing along to these organizations.

Peck: In a recent article in the Journal of the WOCN, you mentioned that one of the first things SNFs need to consider in coping with PPS is improved supply management. Would you elaborate on that?

Turnbull: SNFs must know their own utilization patterns--the types of wounds they treat, the products they use and the costs involved in providing wound care of all types. Before PPS, SNFs didn't know this because they didn't have to. They were cost-reimbursed and, often, an outside agency was doing the Part B billing. Those days are, of course, over. Now is the time for a facility to develop its own wound care protocols--who does what when--and commit them to paper and then into action. Develop a product formulary, purchase one brand when possible and negotiate the contract accordingly. Seek value-added services from that vendor.

Peck: In the article you note that this revised approach can be accomplished for the facility by a WOC (wound, ostomy and continence) nurse. What if the facility can't get the money to pay such a nurse--where does it turn?

Turnbull: The bottom line is that making that upfront investment will save the facility a great deal in terms of lost revenue, fines, legal liability and possible closure, not to mention preserving residents' well-being. But if hiring a WOC nurse remains an impossibility, the facility should make a point of approaching vendors for value added services. The benchmark vendors have unbelievable resources available, and they often provide very generic types of assistance.

The facility should also identify an RN as its wound care specialist, send that person to various conferences and seminars and support him or her in developing an interdisciplinary wound care team--interdisciplinary, because this is the only way wound care can work effectively today. By the way, that designated RN should be in charge of the wound care program, not of changing every dressing. There is often confusion on that point.

Peck: How might SNFs improve their documentation practices?

Turnbull: For one thing, they must make sure that their clinical documentation matches the MDS. They can complete an excellent MDS and still not be paid properly if the clinical records don't support it. Second, a major area of liability in wound care is failure to reassess and reorient treatment if a wound doesn't heal after three or four weeks. Sometimes treatment protocols go on and on for weeks and months. Government is not going to pay for this anymore.

Third, facilities should become acquainted with some of the treatment guidelines available, such as those issued by the Agency for Health Care Policy and Research (now called the Agency for Health Research and Quality) and by the American Medical Directors Association (AMDA). I recently asked an audience of some 300 to 400 nursing home administrators and nurses who had incorporated the AHCPR guidelines into their wound care policies and procedures. About four hands went up--and these guidelines have been out since 1992!

Everybody is seeking a "silver bullet"--the answer--but it's been there all along: Seek good guidelines and implement them according to regulatory standards.

Peck: Is there anything in the PPS process itself that you think should be improved?

Turnbull: To me, the principal area that needs attention is MDS-based wound staging; by that I mean forcing facilities to "back stage" wounds to attain payment. Wounds don't heal that way; a healing wound doesn't go from a stage 4 to a stage 3 to a stage 2 to closure, and yet facilities are forced to "back stage," as it's called, to get payment. I'm not sure what the answer is, but this must be resolved.

Peck: What is the take-home message for readers struggling with skin and wound care under PPS?

Turnbull: It's important to realize that cost-effective care is not necessarily using the cheapest product--in fact, using the cheapest product might be the worst thing you could do, because the outcomes just won't be there. The wound won't heal.

Also I would say, at risk of having things thrown at me, that the PPS is a good thing. I know it sounds like pie in the sky, but facilities really must take steps to improve; PPS is not a perfect system or a finished system, but it's there, and you have to work with it. For a long time you didn't have to worry about these things, because you were being paid whether you were effective or not. We are no longer being paid to treat wounds. Today, we're being paid to heal them.