CareMore Focuses on Treating the ‘Whole’ Senior Citizen

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For the past few years, I have been doing my best to educate wound care professionals regarding the need to proactively develop wound care services as part of disease-management services that span the continuum of care. Typical responses to this concept have included:

• “That’s not our model of care.”
• “If I do that, how will I get paid?”
• “I like working in one place – I do not want to follow the patient into other sites of care – I want all the patients to come to the wound care hospital-based outpatient department (HOPD).”

I always remind wound care professionals that the days of managing chronic wounds in their own silo and not coordinating care as patients move from one site of care to another are becoming short-lived. Wound care professionals have the expertise to manage wounds from start to finish as integral members of the disease-management team and should be the ones to develop wound care services that span the continuum of care.

At the Coalition of Wound Care Manufacturers’ annual “kickoff” meeting in February, I was lucky to hear a fabulous presentation by Tammy Cauthorne-Burnette, MSN, C-FNP, WCC, LNC, of CareMore,^® a medical group based out of Cerritos, CA, that administers a wound care program that treats the patient throughout the continuum of care and integrates that care into a disease-management program that treats the “whole” patient, not “just the hole in the patient.” The most amazing fact I learned from Cauthorne-Burnette’s presentation is that this disease-management program is owned by a payer, Anthem BlueCross BlueShield, and is part of the benefits provided by the various Anthem-affiliated Medicare Advantage plans.

As part of this issue of Today’s Wound Clinic focusing on the roles of various wound clinic disciplines, this edition of Business Briefs will discuss the Anthem-owned CareMore Wound Clinic Disease Management Program and its multidisciplinary team that manages chronic wounds throughout the continuum of care.

Following is an interview with Tammy Cauthorne-Burnette:

Kathleen D. Schaum (KDS): Please describe a brief history of the CareMore Wound Clinic Disease Management Program, including “why” it was created.

Tammy Cauthorne-Burnette (TCB): The CareMore model is designed to detect early symptoms of decline in health, such as poorly managed diabetes and associated wounds and comorbid conditions. Programs are then administered to manage, prevent, and slow health decline. In 2005, CareMore nurse practitioners (NPs) identified wound and ulcer treatment trends in the diabetic patient population seen at CareMore care centers. Patients in the diabetes-management clinics were presenting with ulcers/wounds that were resistive to healing for multiple reasons (eg, lack of knowledge about caring for the wound at home, lack of formal treatment services provided by the primary care provider [PCP], and lack of resources [financial, educational, social, emotional, and /or pharmaceutical]). Therefore, CareMore developed a formal ulcer/wound management program designed to deal with the multifactorial issues that affect wound care and healing. The program targets wound and ulcer prevention not only for the diabetic population, but also for any of our patients who are frail; dependent; and/or at risk for wounds, ulcers, decubitus development, and/or injuries related to falls and fragility — no matter the patient’s age or comorbid conditions.

KDS: How are the CareMore Wound Clinics organized?

TCB: Wound care services are primarily provided at the CareMore Wound Clinic. For patients who are unable to come to the clinic, Touch program clinicians will travel to the patient’s home or assisted living facility, if applicable, to administer treatment. The CareMore Wound Clinic is staffed by advance practice clinicians (APCs) such as NPs or physician’s assistants who are, in most cases, board certified in wound care and ulcer management in addition to receiving didactic training as part of their on-boarding process with CareMore. All CareMore APCs are required to obtain wound care certification once employed.

CareMore invests resources during early stages of illness. Figure 1 depicts how this early intervention can impact disease progression and reduces overall health costs. Care for the wound clinic patient is carried out as a team approach lead by the APC and including dietician, certified fitness trainer, medical assistant, case manager, and, as needed, social worker, extensivist (hospitalist), and behavioral health specialist.

KDS: I understand you used to provide wound care in a physician’s office. From your personal experience, what makes the CareMore Wound Clinic model different from traditional wound care HOPDs or physician’s offices that manage wounds? Provide your personal experience.

TCB: The difference is that CareMore focuses on the whole patient, not solely on the wounds or ulcers. In my primary care private practice experience, it was difficult to afford the overhead of stocking a variety of wound care products in the office. Also, finding and obtaining the durable medical equipment (DME) that patients needed (in a rapid fashion so that a patient could go home with products and supplies after the first visit) was difficult and time consuming. Following are some of the standard operating practices of the CareMore Wound Clinic model:

• Patients may self-refer to the clinic for a wound, ulcer, or injury without a referral from their PCP or specialist.
• Patients are seen at least once per week for evaluation, for assessment of wound changes and infection, and to determine any change in treatment modality or additional services required.
• CareMore providers are trained to evaluate and treat factors that may be affecting wound healing, such as:

• Are the patient’s diabetes or other disease processes controlled and tightly managed?
• Does the patient smoke?
• Does the patient require special nutritional support and education?
• Is transportation a barrier to care?
• What social or financial issues are hindering the care at home and require social services support?

• The CareMore Wound Clinic stocks wound care supplies/dressings and provides them at no cost to patients for their use at home. Additional materials may be shipped to the patient as appropriate.
• The CareMore Wound Clinic stocks DME (eg, post-operative shoes, CAM walkers with offloading inserts, etc.).
• The CareMore Wound Clinic provides diabetic shoes for all patients living with diabetes as a means to prevent wounds.
• The CareMore Wound Clinic APCs educate the patient, families, and caregivers regarding appropriate home wound care management techniques.
• Certain “special needs” plans allow for transportation to the care centers for clinical appointments.
• Patients have access free of charge to Nifty After Fifty fitness and training centers that are attached to the care centers. Nifty after Fifty is a clinically supervised full-body fitness program specifically designed for aging adults.
• Patients may also receive physical therapy at Nifty After Fifty at no additional cost.
• The CareMore Wound Clinic trims nails for those patients living with diabetes on a monthly basis and of other patients on a quarterly basis. This gives clinic staff members the opportunity to prevent and provide early assessment of potential wounds or ulcers.
• Telemonitoring services are used (free of charge to the patient) to help track and manage blood pressure, congestive heart failure, and diabetes.
• Under certain circumstances, the wound clinic home care team conducts visits at no cost to the patient.
• The CareMore interdisciplinary team (known as the Wound War Board) evaluates patients who are at high risk for treatment failure and recurrence on a monthly basis. We also review patients who have healed because we provide regular outreach and serial evaluations to prevent recurrences.
• All care provided by the CareMore center is at no additional cost to the patient.

KDS: Does your health plan’s medical policies control the wound care that you provide?

TCB: CareMore’s treatment guidelines are in accordance with Medicare- and, when applicable, Medicaid-approved therapies.

KDS: Do you use advanced wound care products (eg, cellular and/or tissue based products for wounds [CTPs; old term “skin substitutes”], hyperbaric oxygen therapy [HBOT], multilayer high-compression bandage systems, foam dressings, negative pressure, etc.)?

TCB: We use foam dressings, compression-bandage systems, and other wound care products. If CTPs or HBOT is required, they are provided at tertiary centers.

KDS: Do you use ICD-9-CM/ICD-10-CM codes to prove medical necessity for your work on claims to your plan/other plans?

TCB: Yes.

KDS: Do you use Current Procedural Terminology (CPT^®) codes on claims submitted to your plan/other plans?

TCB: Yes, certain procedures and tests require submission of CPT codes. CPT codes also indicate the type and complexity of visits, such as office visit, home visits, or facility visits.

KDS: Do you use Healthcare Common Procedure Coding System codes for drug/dressing/biologic/equipment on claims submitted to your plan/other plans?

TCB: No, at the present time we are not reimbursed directly for supplies and equipment.

KDS: How are you reimbursed for your work? 

TCB: Medicare Advantage companies are paid directly by the federal government under the Medicare Risk Adjustment payment methodology that began in 2003 as mandated by the Medicare Modernization Act. Reimbursement rates are determined by factors including risk-adjustment codes based on patients’ diagnosis and claims data.

KDS: Do you only manage the care for patients in your health plan?

TCB: Yes, at this time our programs are available only to patients enrolled in the Medicare plans we operate under. However, we are piloting a program in Virginia with select Anthem commercial patients. We are also working with Amerigroup, managing Medicaid patients in Memphis.

KDS: Please share with our readers a typical episode of care at the CareMore Wound Clinic. 

TCB: When a patient presents to the CareMore Wound Clinic, a cascade of no-cost services are typically provided within the first three weeks. I review all the patient’s diagnosis(es)/conditions, develop a plan of care using the services of any/all clinic disciplines needed to manage all the patient’s medical problems, and collaborate with the referring physician (if patient was referred) or care center medical director to implement the care plan. NOTE: Throughout the episode of care, the PCP receives clinical summaries of all CareMore care center clinical visits within 48 hours. Let’s consider this typical scenario: The patient lives with diabetes and depression, has a foot ulcer, is a smoker, is opioid dependent from peripheral neuropathy pain, is a fall risk and needs physical therapy, is confused about his/her medications, and does not have regular transportation.

• I will evaluate the foot ulcer, the diabetes, and comorbid conditions. In conjunction with the PCP, I will also make medication and treatment recommendations and changes.
• The APC will counsel the patient about smoking cessation and may provide a prescription medicine such as varenicline at no cost to the patient.
• One of our behavioral health providers will see the patient to manage depression and substance dependency.
• The social worker will assist in evaluating home safety and financial and transportation needs. 
• The extensivist will see the patient in the Fall Clinic.
• The patient will receive strengthening, balance, and fitness training as well as physical therapy at Nifty After Fifty.
• The dietitian will provide education regarding nutrition and wound healing as well as diabetic nutrition information and guidance.
• The pharmacist will meet with the patient to review medication adherence and cost-effective alternatives.
• The medical assistants will arrange for future transportation, referrals for case management, and appointments for routine nail trims.
• The podiatrist will see the patient at follow-up visits for wound evaluations, for   treatment, and to provide diabetic shoes or orthotics (as appropriate). 

KDS: How do you measure the quality of your work, the total cost of care for the patient living with a wound and patient satisfaction?

TCB: Internal audits review wound care cases. A quality-check committee reviews program efficiencies, which include number of wound visits, hospitalizations related to wounds/ulcers, amputation rates, and, of course, cost of care. We also contract with an outside vendor who facilitates satisfaction surveys of our members.

KDS: Do you benchmark your outcomes with other wound care providers throughout the country?

TCB: Yes. We compare amputation rates, wound-related hospitalization rates, and member satisfaction scores with fee-for-service Medicare patients. The CareMore Wound Clinic is continually focused on improving quality through evidence, effectiveness, and outcomes. By focusing on the entire patient and marshaling resources in the early phase of intervention, CareMore patients have an amputation rate that is 66% lower than Medicare fee-for-service patients (Figure 2).

KDS: What do you see as the future for the treatment and management of wounds?

TCB: Access to quality healthcare will remain the most significant barrier to the management of wounds and the comorbid conditions to which they are connected. Increasing the utilization of telemedicine and virtual care will expand the reach of limited medical resources while improving patient outcomes with a team approach of care specialists as with the CareMore Wound Clinic model. Emerging technologies will allow for new patient and care team interaction using devices that simulate physical assessments virtually. Smart dressings and compression devices capable of providing real-time data or alerts on patient conditions will afford information for diagnoses and treatment modifications at a distance and will potentially reduce the need for office visits – especially for patients not located near a care center. Manufacturers should consider patients with limited mobility and strength, such as arthritis, in the development of future dressings and devices. Reimbursement for wound management, as with all healthcare, is trending toward managed care. Prepayment (capitation) is “freedom,” not a “risk.” It allows us to develop systems to manage care that is individualized and front-end focused for the patient, which should lead to enhanced patient access, compliance, and outcomes.