Effectively Staffing The Multidisciplinary Wound Clinic in 2015

WATCH: Author Melissa Johnson, PT, DPT, CWS, discusses the article. 

Wound care clinicians are firsthand witnesses to the changing healthcare arena in the United States and the reality of quality-based payment. With the increase in patients who are diagnosed with cardiovascular disease, diabetes, and obesity that has occurred over the years there’s also been a dramatic rise in patients requiring specialty services for integumentary care and wound management. Likewise, the practice of wound care has evolved with the emergence of these patients while multidisciplinary wound clinics have become more common across the country. Many years ago, chronic wound patients were treated by physicians, wound ostomy nurses, and physical therapists (PTs) who possessed little (if any) expertise in wound care. Certified wound ostomy nurses typically managed patients both in the acute care setting and occasionally on the outpatient side, providing both chronic wound and ostomy treatments. This care was often fragmented and created “silos” that proved difficult for patients to obtain comprehensive treatment in one setting.

PTs typically coordinated patient care with providers located in separate environments to implement needed procedures such as debridement, ultrasound, electric stimulation (e-stim), total contact casting (TCC), and, at one time, whirlpooling — which is predominately considered to not reflect “best practice” today as the advancement of cleansing and debridement options has continued.

Furthermore, the proliferation of wound and hyperbaric centers in the early 2000s propelled an ongoing effort to bring multidisciplinary care to chronic wound patients into one place for treatment and needed expertise. As wound care has become its own unofficial specialty over the last 20 years with the advancement of technology, research, education, and certification for healthcare providers across the continuum of care and quality has continued to become the main driver for reimbursement, our most-skilled clinicians are now and will increasingly be those delivering multidisciplinary care to wound patients in a single setting. As it stands, educational programs of all healthcare disciplines are already providing more hours of advanced wound care instruction within their curricula and more facilities are staffing multidisciplinary teams to care for wound patients in light of this country’s push towards care quality.

This article will offer the perspective of one such wound care environment and will detail how the wound care staff has been established to meet the demands of recent healthcare delivery trends at Piedmont Healthcare’s Fayette Hospital, Fayetteville, GA, where a successful merger of the physical therapy-based outpatient wound clinic with the inpatient wound ostomy program has created a multidisciplinary wound healing department.

Recruiting the Right Team

One of the most challenging feats assumed by this author when accepting the position of clinical manager wound care and hyperbaric services at the facility in 2006 was identifying a physician champion to serve as our medical director and to lead a multidisciplinary team for our wound clinic — a team that would include a collection of various healthcare providers comprised of multiple specialties who possessed a baseline knowledge of or expertise in wound care and who would give our facility its best chance of providing the highest quality care to drive optimal outcomes. Once the individuals for these positions were identified, we began to build our center, which today is a 4,000-square-foot facility where we see about 220 patients per month.

Being that it’s such a niche “specialty,” the field of wound care presents a unique challenge when recruiting providers who’ve already established with a great deal of clinical experience. And when you take the time to invest in such an initiative to recruit a specialty staff, focus must also be placed on retention in order to offer patients continuity among their caregivers. When choosing our clinicians, we sought those who brought distinct skill sets in order to provide more resources and tools to meet patients’ needs. Nurses certified in wound and/or ostomy care provide a range of knowledge based on skin-related disorders, prevention, ostomy and fistula management, negative pressure wound therapy (NPWT), dressings, and many other techniques learned through their advanced nursing education. PTs have brought a background of biophysical technologies including the use of noncontact and contact ultrasound, e-stim, pulsed lavage, compression, lymphedema management, sharp debridement, burn care, TCC, biomechanics, offloading techniques, positioning and wheelchair seating, and exercise related to disease and movement disorders. As we’ve acquired physicians whose specialties include general surgery, emergency medicine, plastic surgery, infectious disease, vascular surgery, rheumatology, orthopedics, hyperbaric oxygen therapy (HBOT), podiatry, and family medicine the varied backgrounds of these providers has been crucial to the structure of our wound clinic. This philosophy has also lead to referrals to other facility specialists and the ordering of diagnostic tests such as lab work, radiology, imaging studies, and other medically related tests. The physician’s role also includes providing supervision to all other allied health personnel as well as performing procedures such as biopsies, incision and drainage, tissue and bone cultures, bone and muscle debridement, application of cellular and/or tissue based products, epidermal skin harvesting, and HBOT. In addition, the physician supervision and orders allowed other healthcare providers to bill for treatments related to their specific skill set, such as NPWT or noncontact ultrasound. Recently, there has been an increase in the hiring of mid-level providers, including nurse practitioners who are certified in wound care, in our wound clinic, which has allowed for coverage in the absence of a physician. Other healthcare professionals such as hyperbaric technologists have also become an integral part of our team. These individuals have backgrounds ranging from nursing, paramedics, emergency medicine, and respiratory care and they provide treatment and management of patients requiring HBOT under the supervision of a physician. Medical assistants and other professionals with healthcare experience provide supportive roles in the clinic to assist with workflow and daily operations.

Developing Collaboration

Once the multidisciplinary clinical wound care team is formed the goal becomes the development of a collaborative unit that utilizes all skill sets represented in the clinic based on the needs of each patient. Any provider can and will have a different level of knowledge that ones he/she works with, but the entire team must have a shared basic knowledge of wound care and HBOT. Our health system’s wound centers require all clinical staff members to obtain certification within two years of employment. This includes physicians who are serving as medical directors while all other physicians are “encouraged” to become certified or obtain related continuing education credits yearly.  Additionally, all of our nurses and PTs have undergone education related to HBOT in order to remain knowledgeable of these indications and safety issues even though they all may not specifically be providing that treatment.

In order to foster effective collaboration, we identified our managers and those in position of authority (both clinical- and business-related positions) and established protocols and processes (both clinical and business-related practices) that would help us to streamline patient care and to analyze revenue cycles from admissions through discharge. The survival and sustainability of one’s wound clinic, given the recent changes in reimbursement standards, will be based on having key people in positions to manage and monitor the revenue cycle within the wound center as well as the changes that occur yearly related to governmental regulation. Knowledgeable front-end staff members who provide insurance verification, preauthorization, scheduling, and billing are going to be increasingly vital to clinics moving forward. In addition, a basic knowledge of coding, billing, and coverage information needs to be relayed often to the clinical team and other departments to ensure continuity. As a clinical director, this author maintains a collaborative working relationship with individuals in our medical records, coding, billing, revenue integrity, managed care, supply chain, and administrative functions ongoing. This allows our team to work together for the benefit of the patient.

As quality reporting becomes a daily responsibility, it will be those centers with knowledgeable and collaborative practices that will produce outcomes that reflect quality care and healthy revenues.

Melissa Johnson is director of wound care and hyperbaric services at Piedmont Fayette Hospital, Fayetteville, GA.