Wound Care in a PPS Environment.

Cost-effective care has assumed paramount importance

Today, it is virtually impossible to discuss wound care in long term care facilities without discussing payment, regulatory and certification issues. Wound care is a hot topic with payers, accreditors, legislators, regulators, healthcare consumers and attorneys because it has been a focus of prosecution for both malpractice and Medicare/Medicaid fraud and abuse. Quality and cost concerns are further forcing providers to re-evaluate traditional wound care practices. Under the previous cost-based reimbursement system, long-term care providers were paid to treat wounds regardless of the outcomes of their care. Today, providers are being held accountable--clinically and financially--to heal wounds, using evidence-based protocols and nationally accepted clinical practice guidelines, such as those found in the Agency for Health Care Policy and Research's (now known as the Agency for Healthcare Research and Quality) Treatment of Pressure Ulcers. [1]

Under PPS, there is great incentive for efficiency. To survive and remain financially viable, facilities must provide state of-the-art wound care at a lower cost with better outcomes.

Last year, several Government Ac counting Office investigations[2-4] revealed widespread problems in nursing homes, problems that either harmed residents or put them at risk of injury or death. Four of the five most common deficiencies cited in these reports related directly or indirectly to pressure ulcers. At about the same time, the Balanced Budget Act of 1997, focusing in part on reducing skilled nursing facility costs, established a Medicare case-mix prospective payment system, or PPS. Because of this, the Minimum Data Set (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). In turn, because of these advances, the Health Care Financing Administration (HCFA) has the data capability of correlating certain quality care indicators, such as the development of a pressure sore in a low-risk patient, to individual attending physicians' orders. [5]

Nursing home administrators and DONs will be pleased, therefore, that in direct response to these massive changes, the American Medical Directors Association (AMDA) is encouraging attending physicians to have a working knowledge of the PPS system, including elements that drive costs. Additionally, they warn that attending physicians will be held responsible and accountable for understanding the MDS and RUGs patient classification systems, as well as their clinical implications. Attending physicians should anticipate making additional SNF visits as part of a more frequent assessment schedule, and they should presume that the facility will expect residents to be managed aggressively. Finally, physicians are warned that their documentation of resident progress must be complete, sequential and scrupulous. Complications, such as wound infection, will be extremely costly for SNFs; therefore, facilities expect attending physicians to prevent complications if at all possible. According to a former AMDA president, "In the New World of PPS, those physicians who continue to ignore the MDS may quickly become liabilities to the facilities and patients they serve."[6]

While providing seamless, state-of-the art, cost-effective wound care across the continuum seems like a "pie-in-the-sky" impossibility, in truth, it must quickly become a reality. Long-term Medicare providers must now pay all costs for treating and healing wounds under PPS. This does not mean that more expensive therapies cannot and should not be ordered for difficult-to-heal or "stalled" wounds. More expensive aggressive therapies can actually be more cost-effective in the long run if the result is shorter healing time and less resource utilization. Nursing and physician times are the most costly aspects of wound care. Healing rates and time-to-healing resource consumption drive the cost-effectiveness of wound care so any technology that alters or changes the wound environment to facilitate shorter healing times should be considered in the resident's plan of care.

Unfortunately, most facilities have no idea of what it costs to provide wound care, or the differences in their costs for caring for a Stage II or a Stage III pressure ulcer, a diabetic foot ulcer or a venous leg ulcer. Facilities must take aggressive steps to monitor costs, such as establishing in house admission criteria for patients with wounds that enable the facility to deliver quality care below the PPS payment level and still adhere to accrediting, regulatory and payer requirements.

Requiring wound debridement prior to admission, for example, could save days of care, assist in reducing the potential for infection and avoid costly treatment delays. Admitting a patient with a "ready-to-treat, ready-to-heal" debrided wound allows long-term care providers to initiate evidence-based treatment protocols immediately upon admission. This avoids the outlay of precious PPS dollars for in-house debridement or treatment of related infections and complications. In turn, these "saved" dollars can be directed toward immediate healing interventions.

The expertise of wound care specialists (enterostomal [ET] nurses) should be integrated into the plan of care early. 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 in recent literature.[7-12] Facilities should also establish criteria for the utilization of wound care products, such as dressings and specialty beds, and ensure that the plan of care clearly reflects current practice standards. Formularies of wound care supplies should be correlated with clinical pathways that, in effect, become the cost descriptors for specific types of wounds. If wounds do not respond to treatment within two to four weeks, reassessment and changes in the plan of care must be initiated and clearly documented in the clinical record.

A further word about the main players who have not as yet made themselves generally available as a resource for wound management team: physicians. Physicians must become familiar with modern wound care and make themselves available to long-term care centers. A facility benefits directly because a physician's visits are not part of the facility's payment structure under PPS. By getting "buy-in" from physicians, facilities' cost of wound care products can be significantly reduced. For example, it is cheaper and more cost-effective to have wounds debrided by a physician than it is to purchase a $100 tube of collagenase debriding agent. The reimbursement for physician visits is worth the effort to make wound management a part of their practice.

The time has come for all vested parties--administrators, owners, nurses and physicians--to understand that caring for wounds means much more than just changing dressings and doing things because "this is the way it always has been done." For example, the clinical evidence for moist wound healing is simply over-whelming when compared to the results of traditional methods (as will be addressed in a forthcoming issue of this magazine). Taking time to review and understand moist wound healing techniques and learning how to administer them daily is a good investment and use of resources.

Certain products do perform better than others, but it is vital to use products properly. The practice of using products against manufacturers' recommendations should not be tolerated and increases the potential for litigation. An example of this occurred in a Midwest nursing home when a sacral pressure ulcer on a resident was treated with collagenase for more than four years. Collagenase is a chemical debriding agent not intended for long- term use on granulating wounds. However, because it was covered by the payer and the nursing staff and physician writing the orders were poorly educated about wound care, the product was used beyond its efficiency. The wound did not heal and the payer incurred exorbitant expenses. Today's close scrutiny of clinical and financial outcomes permits no toleration of such practices. If a clinician feels he is being advised to use a product against the manufacturer's guidelines (even by a company representative), the manufacturer or pharmaceutical company should be contacted for technical support.

In coming years, more studies must be conducted to compare the ever-growing body of advanced wound care products against one another. If products cost hundreds of dollars, their cost-to-benefit ratio must be clearly demonstrated. A $400 tube of growth factor gel must demonstrate that its cost is worth the outcome attained.

Not only must better wound outcomes be documented, but cost savings must be attained, as well. An in-house team approach to wound care has been shown to work and work well. Taking time to understand techniques such as moist wound healing and using products appropriately in a team context will go a long way to improve wound healing, and result in overall cost reduction and PPS success.

S. Kwon Lee, MD, FACS, a general surgeon, is wound care coordinator for several Northeast Ohio nursing homes and director of the wound care program for University Hospitals Home Care. Gwen B. Turnbull, RN, CETN, is an international consultant on reimbursement and skin and wound care.

References

(1.) U.S. Department of Health and Human Services, Agency for Health Care Policy and Re search Clinical Practice Guideline. Treatment of Pressure Ulcers. AHCPR Publication No. 95-0652, December 1994.

(2.) United States General Accounting Office. Report to the Special Committee on Aging, U.S. Senate. California Nursing Homes: Care Problems Persist Despite Federal and State Oversight. GAO/HEHS-98-202. July 1998.

(3.) United States General Accounting Office. Re port to the Chairman and Ranking Minority Member, Special Committee on Aging, U.S. Senate. Nursing Homes: Complaint/Investigation Processes Often Inadequate to Protect Residents. GAO/HEHS-99-80. March 1999.

(4.) United States General Accounting Office. Report to Congressional Requesters. Nursing Homes: Additional Steps Needed to Strengthen Enforcement of Federal Quality Standards. GAO/HEHS-99-46. March 1999.

(5.) American Medical Directors Association. PPS Basics for Physicians. Columbia (MD): The Association;1998.

(6.) Musher J. President's Message. AMDA Reports: The Newsletter of the American Medical Director's Association. July/August 1998; 14(4):1-2.

(7.) Kerstein M, van Rijswijk L, Beitz J. Improved coordination: the wound care specialist. OWM 1998;44(5):42-6,48,50.

(8.) Granick M, Ladin D. The multidisciplinary in-hospital wound care team: two models. Advances in Wound Care. 1998;11(2):80-3.

(9.) Suntken G, Starr B, Ermer-Seltun J, et al. Implementation of a comprehensive skin care program across care settings using the AHCPR pressure ulcer prevention and treatment guidelines. OWM 1996;42(2):20-32.

(10.) Lancellot M. CNS combats pressure ulcers with skin and wound assessment team (SWAT). Clinical Nurse Specialist: The Journal for Advanced Nursing Practice 1996;10(3):154-160.

(11.) Turnbull GB. Thriving and surviving in home care and skilled nursing facilities under the balanced budget act of 1997. J WOCN 2000; 27:79-82.

(12.) Turnbull GB. Understanding the Balanced Budget Act of 1997. OWM 2000;46(1):40-7.