Building Collaboration Between the Outpatient Wound Clinic and Long-Term Care

  Nonhealing chronic wounds among long-term care (LTC) residents continue to be a concern in the US. Up to 11% of patients in this setting are living with pressure ulcers, according to the National Nursing Home Survey. LTC remains a common environment for wounds due to populations of older residents who are often ill, functionally disabled, and/or at the end stages of disease states. According to the National Center for Health Statistics, prevalence of pressure ulcers in LTC can range from 2-28%.¹ Many of these patients will require repeated visits to the outpatient wound clinic in order to achieve wound closure. This places outpatient wound centers in the unique position of playing key roles to the LTC treatment overview because many wounds do not heal with conservative measures. Additionally, the federal government uses pressure ulcers as a quality indicator in the LTC environment and nursing homes are required to report the presence or development of pressure ulcers through the Minimum Data Set 3.0,² further increasing the likelihood of transfers as a method of best practice.   With strict regulations by the Centers for Medicare & Medicaid Services (CMS) placing more emphasis on quality of care in LTC, those clinicians in this area of healthcare rely on outpatient wound care specialists to meet each resident’s medical needs and assist in adhering to governmental mandates. Wound care providers are also required to remain compliant with the government’s regulations regarding wound documentation and adherence to quality standards of care while patients are in the clinic. As a result of the regulatory issues, associated costs, and patient needs, LTC facilities will often turn to wound care centers for consultation on complex wounds. While the financial burden of wound care may be felt by residents, families, private insurance, CMS, and state Medicaid programs, LTC facilities must also strive to heal wounds at lower cost and nursing time. Wound care providers can assist in this goal by fostering collaboration with residents, families, and LTC staff.

Caring for the LTC Population

  LTC residents referred to wound clinics present unique challenges. The wound care physician, nurse practitioner, or physician’s assistant (hereafter called qualified healthcare professional [QHP]) must remember that the body — and not the dressings — actually heals wounds. This is particularly true of LTC residents, who often represent two very distinct groups: short-term rehabilitation patients who have an expectation of returning home after a short LTC stay and LTC residents who live in the facility for extended periods, often life. The wound care management of short-term patients is similar in many respects to hospital inpatients. This article will focus on the LTC resident.   These residents often have functional debility with impairment of 2-3 activities of daily living such as ambulation, transferring, bathing, toileting, dressing, and eating.³ They often live with dementia, urinary and/or fecal incontinence, and are wheelchair-bound. All these physical and cognitive disabilities dramatically impact the history and physical examination within the wound clinic, so QHPs must be prepared to deal with difficult transfers for debilitated patients. QHPs must also accept indirect historical information, as the patient often cannot provide an accurate wound history. Specifically, nutritional history, mobility, and pressure ulcer information may be challenging to obtain directly from the patient; often QHPs rely upon written notes from the facility. The challenges of diagnosis and determining the needs of the cognitively impaired patient also apply to compliance with the wound care plan. Informed consent for procedures and acceptance of a treatment plan often requires the aid of the healthcare power of attorney or an accepted spokesperson for the patient.   QHPs caring for LTC residents have additional challenges beyond standard wound management. Providing high-quality wound care to the LTC population requires a systematic approach that addresses the wound (diagnosis and treatment) as well as the overall health of the resident. Systemic pathology such as diabetes, heart failure, and cancer are common in older LTC residents and can impair wound healing. The QHP must encourage wound healing via standard techniques such as debridement, infection control, and hydrating wound environment while addressing other risk factors that impede wound healing such as ongoing pressure, ischemia, or edema in many LTC residents.⁴ QHPs must also understand the nutritional aspects of wound care and should address the nutritional status. This assessment may require labs (albumin, cholesterol, prealbumin) in addition to weight and body mass index (BMI). In patients with tube feedings, the adequacy of fluid should be assessed as well as caloric and protein intake through the tube feedings.

Collaborating With LTC

  Chronic wounds require a comprehensive, multidisciplinary approach that includes patient and caregiver education in order to adequately address all patient needs, eliminate duplication of services, enhance patient compliance, and increase patient satisfaction.⁵ One critical component of the wound specialist in relation to LTC residents is the prognosis and possibility of wound healing. Providing an honest opinion on the potential of wound healing is important to the patient, family, and the LTC facility.⁶   Wound clinics may have diagnostic and therapeutic options that may not be available to LTC facilities such as specialized testing (ie, non-invasive arterial testing), hyperbaric oxygen, and ultrasonic mist therapy.^7,8 The ability to conduct specific evaluations helps with the diagnosis of and prognosis for LTC residents. Another fundamental advantage of wound clinics is the ability to perform surgical debridement by skilled QHPs.⁹ LTC facilities are working aggressively to reduce hospital readmissions,¹⁰ and part of this approach involves effective wound care. A dedicated nursing home/wound care relationship may produce further advantages that are not available in the LTC setting. The onsite wound team can evaluate residents in its own environment with a reduction in patient stress and expense while providing ongoing education to the nursing staff, patients, and families face-to-face. The QHP can also observe implementation of the treatment plan on a more consistent basis. The need to communicate directly with nursing staff at the LTC center is especially critical with those patients who live with dementia or other cognitive disorders. Key elements to ensure safe transfer of care should focus on patient-centered care, communication, and safety. Improved communication leads to enhanced patient safety, better outcomes, greater patient and family satisfaction, and reduced length of stay.¹¹ The communication to the LTC facility should include specific documentation of the wound, treatment plan, and prognosis. For documentation, accurate staging of pressure ulcers is a key part of LTC communication and is critical for quality measures within LTC. One uniform provider staging the pressure ulcer is ideal for consistency. Wound plans to LTC should include specific nursing orders (such as turning protocol) with frequency as well as specific wound care dressings, amount (if needed), and end date (if needed). A prognosis helps the LTC staff communicate with the resident and family about the progress of the wound. In particular, if the QHP believes the wound will not heal, discussing palliative wound options is appropriate and encouraged. Nutritional support is another important issue for many LTC wound care patients, as nutritional deficiencies are common when patients become frail and require LTC stays. Awareness of potential nutritional deficiency should be a concern for any LTC patient in the outpatient clinic, and QHPs should comment and document nutritional status when a resident is evaluated. Ideally, all patients are weighed and have BMI documented at each visit to evaluate weight changes. The use of supplements often remains a challenge in LTC, as some residents will not drink supplements. Working with dietary support staff within the facility may improve compliance with nutritional intake. A summary of issues faced by many LTC residents is in Table 1.

The Reimbursement Piece

  Payment restrictions often limit wound treatment options in LTC. Administrators are often forced to tightly manage resources for wound care, including nursing time and wound products. QHPs in the outpatient center should take time to communicate with LTC staff and help them understand that lowest-cost products may not produce the lowest total cost of care, the best outcomes, and/or the greatest patient satisfaction. LTC payment often involves Medicare Part A insurance for short-term residents, which is a per-diem prospective payment system. This one payment includes all resident costs including wound supplies and nursing time. Restricting wound care formularies is one method of controlling costs; thus, expensive wound options like silver-based therapies may not be available. LTC facilities also limit advanced wound technologies because of staffing, patient volumes, and economics. Thus, outpatient clinics must be aware that facilities are mindful of costs. If a QHP feels strongly that a wound treatment plan requires an out-of-formulary exception, it might be best to work with the director of nursing at the facility or the medical director. Les Kiemele and Paul Takahashi are on staff at the Mayo Clinic College of Medicine, Rochester, MN.

References

1. Park-Lee E, Caffrey C. Pressure ulcers among nursing home residents: United States, 2004. NCHS Data Brief. Feb 2009(14):1-8. 2. Levine JM, Ayello EA. MDS 3.0 section M: Skin Conditions: what the medical director needs to know. Journal of the American Medical Directors Association. Mar 2011;12(3):179-183. 3. Gill TM, Gahbauer EA, Han L, Allore HG. Functional trajectories in older persons admitted to a nursing home with disability after an acute hospitalization. Journal of the American Geriatrics Society. Feb 2009;57(2):195-201. 4. Takahashi PY, Kiemele LJ, Jones JP, Jr. Wound care for elderly patients: advances and clinical applications for practicing physicians. Mayo Clinic Proceedings. Feb 2004;79(2):260-267. 5. Bogie KM, Ho CH. Multidisciplinary approaches to the pressure ulcer problem. Ostomy Wound Manage. Oct 2007;53(10):26-32. 6. Jaul E. Non-healing wounds: the geriatric approach. Archives of Gerontology and Geriatrics. Sep-Oct 2009;49(2):224-226. 7. Kranke P, Bennett MH, Martyn-St James M, Schnabel A, Debus SE. Hyperbaric oxygen therapy for chronic wounds. The Cochrane Database of Systematic Reviews. 2012;4:CD004123. 8. Ennis WJ, Foremann P, Mozen N, Massey J, Conner-Kerr T, Meneses P. Ultrasound therapy for recalcitrant diabetic foot ulcers: results of a randomized, double-blind, controlled, multicenter study. Ostomy Wound Manage. Aug 2005;51(8):24-39. 9. Levine SM, Sinno S, Levine JP, Saadeh PB. An evidence-based approach to the surgical management of pressure ulcers. Ann Plast Surg. Oct 2012;69(4):482-484. 10. Ouslander JG, Lamb G, Tappen R, et al. Interventions to reduce hospitalizations from nursing homes: evaluation of the INTERACT II collaborative quality improvement project. Journal of the American Geriatrics Society. Apr 2011;59(4):745-753. 11. Cioroiu M, Levine JM. Improving Communication in the Wound Clinic. Today’s Wound Clinic. 2013;7(3).