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Wound care post-PPS: are these vendors showing the way?

Wound care programs are claiming results that seem made to order for PPS

Post-acute care providers have, to some extent, felt under siege since the advent of the Medicare Prospective Payment System (PPS) in their lives. The novelty and complexity of the new reimbursement rules have, by various accounts, flummoxed more than a few (and the rules aren't even finalized yet). A result, for some, has been a pulling back from the delivery of more costly forms of care - less contracting, less purchasing, perhaps even less care - at least until some sense of financial confidence returns. By the accounts of several observers in the field, wound care has been no exception to these trends.

There is no shortage of companies, however, that are still offering this service and are trying to demonstrate that the most cost-intensive way, at least up front, might actually be the best way to survive and prosper under PPS. The companies range from small to large, from itinerant clinical consultants to national firms providing inpatient referral resources.

The 155-bed Whitehall Boca Raton skilled care residence in Boca Raton, Florida, has engaged a physician who provides team intervention to manage its wound care.

Heading up its "wound team" is Louis A. Viamontes, MD, president and owner of Wound Clinics of America. based in Stuart, Florida, the independent firm currently maintains wound management contracts at 20 nursing homes throughout Florida, from Jacksonville in the north to South Beach in Miami. He also plans to deploy clinical programs in three New Jersey facilities early this year. A board-certified vascular surgeon with 20 years' experience, Dr. Viamontes makes weekly visits to Whitehall Boca Raton and the other facilities his company serves.

Others on the wound team include Dr. Viamontes' clinical registered nurse/wound care specialist, Suzanne Artz, RN, CWS; Whitehall's restorative nurse, Gloria McCann; and registered dietitian Lori Bender, RD, CDE, LDN.

McCann, who has become familiar with Dr. Viamontes' protocols, evaluates and initiates wound treatment for residents who are admitted between Dr. Viamontes' weekly visits. She generates a list of residents who are to be seen during wound rounds, gathers their medical records and is responsible for requesting orders from attending physicians for Dr. Viamontes to evaluate and use in treating the residents' wounds. (Physicians who choose to provide their own wound care are offered suggestions and recommendations by the team.)

Suzanne Artz assists in the physical assessment, while Gloria McCann provides pertinent clinical information and assists in the documentation process and in developing a positioning, pressure reduction and continence management program.

Prior to wound rounds, dietitian Lori Bender gathers all of the weights for the residents, pertinent laboratory results such as serum albumin or prealbumin, and recent dietary and fluid intake, and calculates the nutritional requirements for each resident.

A physical therapist provides information related to the residents' physical activity and progress, and any positioning or orthotic devices that might assist in their care. At Whitehall, the nurse and aide caring for each resident are also encouraged to attend rounds for their patients.

During Dr. Viamontes' rounds with the team, he enters all patient and wound information into a laptop database, enabling him to generate various printed reports and statistical analyses for Whitehall staffers to use on the spot. Wound rounds include a systems review, physical examination, and nutritional and physical therapy assessments, as well as complete assessment and measurement of each wound. Dr. Viamontes addresses the wound etiology, including contributing and exacerbating factors, and then develops a plan of care that might include additional vascular studies, positioning and pressure reduction strategies, nutritional intervention and adjunctive physical therapy treatments.

Dr. Viamontes has developed his wound management protocols over the past 20 years and, based on more than 2,000 wound assessments a month, has access to an extensive wound outcomes database. He has found that the choice of wound care products is more critical for outcome in a stage II pressure ulcer than in a stage III or IV pressure ulcer. His data show, for example, that more than 98% of the stage II pressure ulcers treated with the Smith + Nephew products he prefers (Skin Prep[TM] and Allevyn Adhesive[TM]) resolve within 8 to 10 days, while 16% of those treated with a hydrocolloid progress to a stage III or IV.

With a wound-resolution time averaging 28 days for every wound treated, a decrease in the number of wounds progressing from a stage II to a III or IV, and a decrease in nursing time with the three-times-weekly dressing changes, Dr. Viamontes' program has reported significant overall cost savings. Total cost for treating a stage II pressure ulcer to healing is about $38, he reports, which includes the product used as well as the nursing time devoted to wound care.

Moving up the organizational scale, Derma Sciences, Inc., a vendor of wound management services based in Princeton, NJ, reported a test several months ago of its Optimum Outcomes Wound Management System applied by the Bayada Nurses Home Health Specialists agency in New Jersey. The system includes Derma Sciences zinc-nutrient-formulated products, combined with staff education, wound-specific care plans, protocols and outcome measurement tools. For the test, physicians and home health nurses used conventional treatments for such wounds as decubiti, stasis ulcers, ischemic ulcers and surgical site wounds for 30 days; after this time, if the wound had not healed, they adopted the Optimum Outcomes system. The result, according to the company, was a quadrupling of wounds healed and a decrease in average time for wound closure from 61 to 29 days. Average cost to heal a wound dropped from $5,500 to $1,825, and the number of home health visits required dropped from 68 to 25, according to the Bayada results.

At the opposite end of the continuum-of-care spectrum are the Wound Care Centers operated by Curative Health Services, based in Hauppauge, NY. Some 130 such centers are affiliated with acute care hospitals throughout the United States, and the company has been expanding into other care settings. The company features treatment with Procuren, a growth factor solution, but also brings to bear a broad armamentarium, including assessments with laboratory, radiologic, nutritional and vascular studies; surgical treatments; infection control; pressure relief measures; and basic skin care. The company claims an 80% cure rate for wounds that had been otherwise resistant to therapy.

All of these approaches share two things in common: (1) each features a proprietary and/or brand name product, and (2) they apply focused, multidisciplinary techniques for the sole purpose of wound assessment and healing. Proprietary products are what they are - either they prove themselves in the "heat of battle" or they don't. But every facility has within its control the ability to organize or contract appropriate staff and technology to optimize wound care. It might seem an expensive way to go in these days of PPS-inspired fear and confusion. But it just might, in the end, be the key to success.

Richard L. Peck is editor of Nursing Homes/Long-Term Care Management. Myra Gross is a writer based in Plantation, Fla.
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Title Annotation:wound care programs in nursing and long term care facilities in wake of the Medicare Prospective Payment System
Author:Gross, Myra
Publication:Nursing Homes
Date:Apr 1, 1999
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