The Future of NPs in Wound Care: Delivery of Quality Care & Cost Savings?

  There is a continually growing need to shift traditional wound care practice into what is now considered “best practice” and “advanced wound care” with the availability of evidence-based information. With this growing body of evidence-based knowledge, there is also a need for specialty wound care at all levels. An increasing number of physician practices that specialize in wound care are developing, and growth in companies that devote resources to managing wound care patients in all settings is evident. As these trends continue, hiring more specially trained nurse practitioners (NPs) will expand both the reach and the knowledge of those who offer advanced wound care.   This article will examine the role of NPs and detail how wound care centers in particular are benefiting from their utilization when appropriate training and education are considered.

Nurse Practitioners: A History Lesson

  NPs have struggled to gain acceptance from the medical community as a whole, as the concept of physician extension, both from a consumer and regulatory standpoint, has taken time to develop. This slow-moving appreciation has been exacerbated by the economic pressures placed on physicians, especially those who practice primary care. Some have seen the role of the NP as a threat to revenues as they consider the educational costs for NPs is about 1/4-1/5 the cost of medical school while NP salaries can be as high as half of that for physicians. However, in 1986 the Office of Technology Assessment (OTA) looked at overall performance of NPs and determined they deliver service at equal quality when compared to primary care physicians.¹ In time, however, most physicians have come to view the NP as a vital part of the healthcare team who’s needed to deliver the best outcomes at the lowest possible cost. Additionally, patient satisfaction rates for NPs in relation to care and services provided, test results, and health status are similar to what they are for their physicians. The savvy physician recognizes the NP saves time, improves continuity of care, is accepted by patients, and can rival the performance of the physician.¹   Today, the expansion of NPs within the wound care market parallels the expansion of their roles within medicine in general. The American Academy of Nurse Practitioners (AANP) reports approximately 155,000 practicing NPs. Despite the fact that this organization doesn’t offer clinical resources for wound care among its 14 specialties available to NPs, the overall growth of NPs in wound care coincides with an increase in the number of wound care practices across the country and the addition of the NP as a key professional for many of these practices. Having a workforce of physicians and NPs improves continuity of care across healthcare venues. When a patient can be seen in the hospital, transferred to a skilled-nursing facility, and have care completed in an outpatient wound care center, coordination of care and patient outcomes improve.   As the wound care specialty continues to develop and the need for wound care specialists continues to expand, the importance of care coordination throughout the continuum cannot be underestimated. The utilization of NPs and even physician assistants (PAs) will continue to grow and become a more integral part of the development of wound care as a specialty. Specially trained advanced registered nurse practitioners (ARNPs) and PAs are uniquely positioned to provide excellent quality and cost-effective care in both acute and post-acute settings, and staffing agencies across the US have seen tremendous success and growth in the recruitment of NPs, PAs, and ARNPs for hospital and skilled-nursing partners who recognize the importance of such collaboration. However, the importance of initial training and ongoing education that’s required in order to maximize the potential for quality outcomes and patient satisfaction/safety while fostering this collaboration cannot be overemphasized.

Recruitment of NPs

  For those wound care centers looking to expand in practice, adding or supplementing staff with an NP can improve the profitability without a reduction in quality of care. Note, however, that development of the competencies and capabilities required to perform this role should be considered the first step for a successful recruitment strategy. How is one going to know when the best candidate is found if one has not defined the need? Competencies in wound care include, but are not limited to, diagnosing wound etiology, evaluating and considering patient complexities (including comorbidities), possessing skills in wound assessment and debridement, and recognizing the atypical wound. But each particular healthcare setting has its differences. An NP in a long-term care (LTC) facility must know the appropriate regulations, the culture, and the needs of primarily geriatric patients. An NP in an outpatient wound clinic will need to be able to function in a faster-paced environment as well as be able to determine when to use advanced technology such as skin substitutes and hyperbaric medicine. It would be unusual to find an NP who holds both skill sets and inclinations. And although adult primary care or gerontology practice experience is a basic requirement when recruiting for additional positions, expecting extensive wound care experience would be optimistic at best. According to Charleen Ise, MD, medical director with Healogics Specialty Physicians, the nurses who hold the skills that best dovetail with wound care possess dermatologic; surgical; family medicine; and previous wound, ostomy, and continence experience.   Anyone recruiting an NP into the wound care setting should set standards that require patient-assessment skills, knowledge of physiology, team orientation, efficiency, and ability to embrace change and manage a lifelong learning process. Because wound care is constantly evolving, staying abreast of the growing knowledge base is critical. Once these requirements are defined, the process of determining where to seek qualified professionals can begin. An online job search for the title of “nurse practitioner” reveals no less than eight sites that specialize in placement of NPs. Professional organizations, nursing schools, and other job boards serve as additional sources, as do direct website job listings. However, using current staff members as resources and investigating their networking contacts can also be useful and may prove to be the best source of appropriate and qualified individuals. Once a pool of candidates is identified, the real work of finding the best fit means having multiple interviews conducted by stakeholders. One strategy is to involve the top candidates in learning the day-to-day role for which they are being hired. After that, the requisite background checks and references need to be completed before the final negotiation and contractual agreement can be executed. If not performed diligently, this lengthy and involved process may result in job dissatisfaction and turnover, which is very costly with highly qualified professionals. NPs report greatest job satisfaction with collegiality of relationships within the practice along with challenge and autonomy.² Ensuring the practice can meet those top desires for individual candidates will pay off in better retention. A high-quality recruitment process that matches candidates with the outlined requirements will increase the likelihood of a successful hire.

Providing Appropriate Training

  Training to be a wound care practitioner begins with the required core competencies and capabilities previously discussed. It is rare to find an NP who already holds all the requisite skills and knowledge to perform effectively from day one. A program that combines classroom-level didactic work with online courses and required reading materials as well as an individualized preceptor program is fundamental to developing a competent and confident provider. This type of comprehensive training program produces providers who see patients efficiently and effectively while delivering desirable wound care outcomes. Ongoing mentoring from collaborating physicians remains a key part of the training process. All wound care providers need additional resources to be effective. This collaborative approach to care is an important reason that the specialty and business of wound care has grown so dramatically. Beyond receiving consults from their peers, NPs should have access to a certified wound specialist as the supervising physician. Generally, the training process takes between 6-12 months. During this time, NPs will have exposure to a variety of wound types and patient complexities in order to handle most patient care issues in stride. Beyond initial training, additional resources and educational opportunities should continue to be available, including evaluation of case studies, treating difficult-to-heal wounds, and reviewing patient data and outcomes.

Future Of The NP In Wound Care

  Given the anticipated influx of patients as the Affordable Care Act’s impact increases, economic pressures to reduce healthcare costs strengthen, and the evolving role of NPs in all medical specialties is solidified, one can certainly expect NPs to take on a greater role in wound care moving forward. It may be that NPs will serve most roles particularly within the LTC sector, where there are more regulatory stipulations to contend with and probably more of a need for more frequent comprehensive patient assessments provided by a medical practitioner. Primary-care physicians may only see these patients monthly after their initial assessments upon admission to a facility, allowing more time to pass and wounds to develop. LTC patients are often admitted with wounds of various etiologies, and the primary physician may have only extended orders that came with the patient from the hospital. The initial evaluation for wound care is critical to achieving a successful wound care program. A comprehensive evaluation is best performed by a qualified wound care practitioner in order to develop the best treatment plan and achieve positive outcomes.   Due to a shortage of primary care physicians that is only expected to worsen, NPs are taking on the assessment role in many settings, such as physician offices, nursing homes, and hospitals. As healthcare officials anticipate seeing more patients, providing effective wound care will continue to become more of a challenge. Projections estimate there will be 198,000 NPs providing direct patient care by the year 2025. This is a 130% increase from 2008, when there were 86,000 NPs providing patient care in the market. It is also estimated that the ratio of physicians to NPs will fall from 5:1 to 3:1 by 2025.³ Although wound care may be practiced in almost every setting, there may be a significant difference in the quality of wound care treatment based upon the experience and education of the provider.   Adding education on preventive strategies as part of the service provided by the NP along with diagnostic, interventionist, and medical oversight required to optimize outcomes makes their services more valuable. In the wound clinic, NPs have been approved to supervise hyperbaric oxygen therapy in many areas, although this differs from state to state and by payer. With the difficulty of finding enough physicians in some of the more rural markets, this may be a viable strategy for primary and secondary medical coverage, as well as for extending clinic hours to accommodate a higher patient caseload.

NP Value To Wound Care

  As the specialty of wound care continues to grow, the need for qualified and dedicated NPs will also increase. Recruiting and retaining NPs will pose a challenge that the industry must successfully meet if wound care is to thrive and grow to achieve the best outcomes possible. In view of growth of the elderly population that’s experiencing the greatest number of wounds, a team of oriented professionals who know the industry and the complexities of the wound care population will remain paramount. Chris Morrison is executive medical director and Linda Miller is director of clinical operations at Healogics Specialty Physicians. References 1. Alpert PT, Fjone A, Candela L. Nurse practitioner: Reflecting on the future. Nursing Administration Quarterly. 2002; 26(5):79-89. 2. De Milt DG, Fitzpatrick JJ, McNulty R. Nurse practitioners’ job satisfaction and intent to leave current positions, the nursing profession, and the nurse practitioner role as a direct care provider. J Am Acad Nurse Pract. 2011; 23:42-50. 3. Scudder, L. Growth of the nurse practitioner workforce. MedCare. 2012. Accessed online: www.medscape.com/viewarticle/761728.