Effective Care Planning Between the Wound Clinic & Skilled Nursing

Does your outpatient wound care program provide care and direction for nursing home patients who are living with chronic wounds? If so, you are working with one of the most challenging patient populations in the country. When a wound care clinic (“the clinic”) accepts a resident from a skilled nursing facility (“the facility”), it means the facility has not been able to close a wound or that there are particularly challenging wounds present that require specialized clinical expertise. Creating a meaningful collaboration between the clinic and the facility is important and can be done when approached with respect for each care setting’s strengths and challenges. This article will offer suggestions to outpatient providers who may be facing difficulty when navigating this type of care along the healthcare continuum. The aim of this article is also to provide insight from both perspectives and to assist those who work in these settings to successfully meet the goal of providing care that meets the standards of practice for wound management.

Wound Care & Skilled Nursing
Many long-term care facilities employ well-trained wound care nurses; however, not everyone is properly educated in current evidence-based care of chronic wounds, which creates the need for outside expertise to help manage these challenging patients. A facility may have had a wound management provider group that conducts rounds, assesses wounds, and gives direction and orders for providing care. These relationships with outside providers can change, requiring facility management to seek different options to assure that difficult wounds are being managed in an expeditious and evidence-based manner. Wound clinics are often the answer to providing a level of wound care and management that facilities cannot provide for their residents. The relationship with the wound clinic also helps the facility to meet the federal regulations related to quality care, specifically related to current evidence-based and best practices for wound management. It is important for everyone involved in the delivery of care to understand that the facility has not been relieved of the responsibility for the care and outcomes of the wound when a patient is under the care of a wound clinic practitioner, according to federal regulations that continue to hold the facilities responsible for wound progress and healing. The facility is mandated by the Centers for Medicare & Medicaid Services (CMS) to provide care that meets professional standards of quality. “Professional standards of quality” means that care and services are provided according to accepted standards of clinical practice. Standards may apply to care provided by a particular clinical discipline or in a specific clinical situation or setting. Standards regarding quality care practices may be published by a professional organization, licensing board, accreditation body, or other regulatory agency. Recommended practices to achieve desired resident outcomes may also be found in clinical literature. (Reference F658 in Appendix PP of the State Operations Manual – Guidance to Surveyors for Long Term Care Facilities [SOM].¹) The facility must provide care in-house or find community expertise, in addition to arranging transportation to and from the community care site. Open two-way communication between the clinic and the facility is critical for continuity of care and is one of the most important components of the framework for caring for the resident living with a chronic wound. 

Wound Care & Skilled Nursing Collaborative
The clinic and the facility can get the most out of this collaborative relationship by understanding the needs and expectations of each practice site with the goal of delivering safe and effective care for this challenging population. The provision of care in a long-term care setting is no longer simply “activities of daily living (ADLs) for the elderly and infirm who can no longer live independently,” although that may still be occurring. “Residents” are defined as such because that is where they reside. However, the acuity level of these residents has increased exponentially in recent years as medicine has provided longevity for those living with chronic illnesses that was not possible previously. Residents are sicker, with more comorbid conditions than before, creating additional challenges for managing and closing chronic wounds. Let’s discuss some common challenges for each care setting. (Note that this is not an exhaustive review.)

The Wound Clinic
The clinic operates Monday through Friday and will usually have someone on call after hours and on weekends. The practice is based on appointments and usually runs on a tight schedule with rapid turnover of the rooms. The number of treatment rooms can vary greatly and is usually a combination of rooms with stretchers/gurneys and podiatric chairs. Most clinics require a representative from the facility to accompany the patient using reliable transportation. A few significant points:

• Clinic staff members are not able to stay in the room with the resident the entire visit. So, from a safety perspective, as well as to reduce the stress for the residents, someone who knows them from the facility can meet those needs by being present in the room. 

• Often, residents are transported to their appointments during the day at times that cause meals and/or snacks to be missed. Send a snack along with the resident in the event of delays, such as travel issues or appointment delays due to a clinic schedule backup. This is particularly important for people living with diabetes who take medications that lower blood glucose, especially insulin.

• Patients should be transported efficiently, as timing and promptness in picking up the resident to return to the facility is important. When the visit is completed, it is important that the resident be removed from the room so that the room can be cleaned and prepared for the next patient. There have been instances when the resident’s transportation personnel have left the person at a clinic for multiple hours, causing discomfort and stress for the resident as well as tying up the room, negatively impacting the center’s patient flow, and delaying visits for other clinic patients.

• If the patient needs to be moved utilizing a lift, it is helpful that the patient be sent from the facility already positioned on the sling. It can be difficult to position a sling under a patient in a wheelchair or on a transport gurney in a small clinic's examination rooms.

• Residents living with pressure ulcers/injuries will need to be repositioned if the wait for care at the clinic is long. The facility staff member may need assistance from clinic staff if repositioning is necessary. However, clinic staff will not take the lead on repositioning the resident. That responsibility belongs to the facility.

• If the resident utilizes a containment brief/adult diaper, send an extra to the clinic in case it is needed.

• The initial visit will be longer to review patient history; document medications; conduct a thorough evaluation; and identify, measure, and photograph wounds. To maximize this visit, the more information that can be provided from the facility for evaluation, the better. This should include:

- the most recent history and physical and pertinent surgical interventions;

- complete medication and treatment list;

- any diagnostics that are available (eg, arterial or venous dopplers, current glucose log, most recent chemistries [including A1C, if diabetes is a diagnosis], complete blood count or any other pertinent labs, and any nutritional assessments);

- the facility wound assessment records and previous treatments; and 

- communication from the facility as to what type of documentation is needed after the resident’s visit.

The Skilled Nursing Facility 
There are multiple challenges in every healthcare setting for providing quality care that meets current best practices. Originally, skilled facilities were set up as care sites for people who required long-term onsite supervision, assistance with ADLs, and minimal-to-moderate levels of clinical care and interventions who did not require the intensity of care provided in an acute care hospital. Today, the patient population is at the highest acuity level seen in this industry since its inception. Many facilities are caring for patients and residents who would have been receiving care in an acute care hospital in the recent past. In addition, current hospital practice is to discharge patients as expeditiously and safely as possible, which may be a further challenge if the resident is returned to the facility on the heels of a critical illness. The business model (having adequate census and case mix) creates the need for facilities to admit higher-acuity patients. The higher acuity requires increased staffing and elevated levels of clinical competency and supervision, creating necessary changes in the industry to provide adequate care. In addition, skilled nursing is one of most highly regulated industries in the United States. The industry must meet defined criteria to be eligible to serve patients and residents in their buildings and to be reimbursed by CMS. The primary resource for guiding the facility in providing care for residents is the SOM.¹ Another core document from CMS that drives accurate and effective resident assessment practices, documentation, and reporting is the Resident Assessment Instrument (3.0),² which is often referred to as MDS (Minimum Data Set). Section M of this document gives the facility instructions for the resident’s overall assessments and coding and reporting of skin conditions, including wounds, to CMS. The MDS and the SOM are the primary documents for guiding facilities through the Long-Term Care Survey Process.³ 

Issues Affecting Care Continuity 
Challenge: The facility has protocols and formularies for wound dressings/products that may be limited to what the durable medical equipment (DME) provider has in its formulary that meets the CMS surgical dressing policy criteria, or the facility has a contract with a wound product company that differs from the branded product that the clinic orders. If the clinic practitioner writes an order for a product that is not in the facility’s formulary or a dressing that the contracted DME company cannot provide, the facility must either buy that product and incur higher costs or not buy the product and be out of compliance with the regulations because the practitioner wrote an order for a specific brand of dressing for which the facility could not provide. In addition to the type of dressing order being an issue when brand names are used, the frequency of change (FOC) order will need consideration by the clinic practitioner for the facility to stay in compliance with the federal regulations.

Suggestion: It will help the facility if the clinic practitioner writes the order for a dressing category (eg, foam) rather than a specific brand name. Allowing for substitution with another equal brand will reduce the risk of a delay in care and go a long way in creating collaboration and understanding between the two care settings. The manner in which the clinic practitioner writes an order for the FOC of the dressing can be an issue if not looked at from the facility and CMS perspective. An example would be “foam dressing on wound three times per week and prn.” CMS interprets this as “three times per week.” In other words, the least number of changes written in the order. The practitioner had a great reason to write the order this way because the resident is incontinent, and the clinic practitioner wanted the facility staff to have flexibility in using the dressing when there are bouts of incontinence that soil the dressing and put the resident’s skin at risk for breakdown. It will be helpful if the clinic practitioner takes into consideration the resident’s conditions, such as incontinence, and writes how many times per day/week/month dressings may need to be changed. Basing the FOC order on the history of the specific condition that may damage/soil/displace the dressing will go a long way in assisting the facility with serving its residents, reducing facility costs, and staying in compliance with the regulations. 

Challenge: Clinics may not be aware of federal and/or state regulations that question treatments considered below the standards of practice. This can be problematic for a facility and may incur an F-Tag (deficiency citation) if the surveyor determines the treatment is below practice standards.

Suggestion: Any deviation that could be interpreted below the standards of care by a surveyor (eg, repeated wet-to-dry dressing on seemingly healthy wounds, using cytotoxic agents long term) may have justifiable reasons for being ordered, and these should be documented in the practitioner’s notes. Ideally, the practitioner will be open to an alternate treatment that conforms to regulatory guidelines and practice standards. 

Challenge: The facility is required to report to CMS the correct etiology of the wound. The documented etiology from the facility may differ from the etiology identified by the clinic. There can be several reasons for this, including the fact that some wound etiologies look similar and that misidentifications are made. In addition, the center will have ready access to diagnostics that are not readily available in the facility, such as ankle-brachial index testing.

Suggestion: If it is recognized that there is a discrepancy between the facility and the clinic’s documented diagnosis (eg, heel pressure ulcer versus diabetic foot ulcer), then it would be helpful to have a discussion with the director of nursing, treatment nurse, or medical director at the facility. This will enable clarification for correcting the etiology in the medical record as well as the MDS Section M for reporting to CMS. This conversation must take place and can be collegial and meaningful. The facility staff members are mandated to correct the etiology, if it was their error. This requires respectful collaborative communication between the care settings.

Challenge: The clinic and facility have different stages documented for pressure ulcers/injuries. Staging is a skill and even the most knowledgeable clinicians make staging mistakes occasionally. The National Pressure Ulcer Advisory Panel (NPUAP)⁴ is the organization that writes and publishes pressure ulcer/injury staging descriptions. CMS has adapted (not adopted) these descriptions and has written them into its regulatory and reporting documents. CMS has also stated that when documenting wounds related to pressure that the use of either term, “ulcer” or “injury,” is acceptable, so this is not an issue for documentation in facilities. What is an issue, for example, is when one care setting documents the pressure injury as a stage 2 (partial-thickness wound) and the other a stage 3 or 4 (full-thickness wound). This inconsistency will be challenged by surveyors, if noticed.

Suggestion: Any discrepancy in staging of pressure ulcers/injuries should be resolved between the clinic and the facility. When there are different perspectives about staging, consult the NPUAP, the SOM, or MDS, and review the staging categories to ensure that what is documented meets the descriptions from these resources. An example would be a wound that is categorized as “stage 2 pressure injury.” The wound base is documented as having slough, which does not meet the description of stage 2 pressure injury from any of the aforementioned documents.

Challenge: Sometimes, the clinic has a dressing that the practitioner has ordered to be left on until the resident’s next visit. An order to not change or take off the dressing until the resident returns to the center is fraught with problems for the facility. 

Suggestion: If this order is necessary due to a specialty dressing or intervention that cannot be done in the facility, such as cellular and tissue-based products, then ensure the resident comes back to the clinic in a short time period, perhaps the same week, or provide an order allowing the facility to change the secondary dressing — leaving the contact layer and specialty product intact on the wound surface. The facility needs flexibility, as wounds are dynamic and can change rapidly while requiring increased vigilance, unexpected dressing changes, and even a new assessment of the resident and the wound (if there has been a change in the resident’s condition). 

Challenge: The practitioner orders a specific pressure-redistribution device that the facility may not have access to. 

Suggestion: Call the facility to see which options are available for pressure redistribution. This collaboration facilitates the facility in using options available on its formulary of surface products and helps to be in compliance with the regulations while staying within budget.

Challenge: The resident arrives with a soiled brief, seemingly unclean and unkempt, resulting in a negative comment about the resident’s hygiene in a progress note by the practitioner.  

Suggestion: Be mindful that the residents are on a bathing schedule and are not bathed daily, which is an accepted practice in the facility setting. The resident soiling on the way to or at the clinic is an unpredictable occurrence. 

Summary
The challenges discussed in this article are based on observations, personal experiences, and discussions by clinicians in both care settings, and may not be comprehensive for all challenges. Readers will be invited via email to provide insight on the challenges they face and the suggestions they have to offer for collaboration and caring for patients and residents in long-term care who need the expertise from the wound clinic professionals. Working together collaboratively enables optimal outcomes for patients/residents while meeting the needs of the clinic, and the facility. n

Pamela Scarborough is director of public policy and education at American Medical Technologies, Irvine, CA, and is on staff at the Archbold Center for Wound Management and Hyperbaric Medicine, Wimberley, TX. Dot Weir is on staff at Advanced Wound Healing Centers, Catholic Health System, Buffalo, NY. Both women are also members of the TWC editorial advisory board.

Carolyn Cuttino, RN, BSN, CWCN; Cheryl Lytle, PT, MS, CWS; and Misty Vaughn, PT, MS, CWS, contributed to this article.

1. State operations manual appendix PP - guidance to surveyors for long term care. Rev. 173. 2017. CMS. Accessed online: www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/som107ap_pp_guidelines_ltcf.pdf 

2. Long-term care facility resident assessment instrument 3.0 user’s manual version 1.16. CMS. 2018. Accessed online: https://downloads.cms.gov/files/1-mds-30-rai-manual-v1-16-october-1-2018.pdf

3. Long term care survey process (LTCSP) procedure guide. CMS. 2018. Accessed online: www.cms.gov/medicare/provider-enrollment-and-certification/guidanceforlawsandregulations/downloads/ltcsp-procedure-guide.pdf

4. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and treatment of pressure ulcers: clinical practice guideline. Cambridge Media: Perth, Australia; 2014.