Taking It to the Streets: Traveling to the Patients

  As wound care providers, we are all too familiar with a situation that exists where patients under our care may, for any number of circumstances, be “lost to follow up”. In some cases, these patients may eventually find their way back to your service, and you may experience the frustration of being back at “square one” or worse.

  Some patients in need of your services may not physically be able to be transported to your wound center. How do these patients receive expert wound care from a wound specialist? Very often, they don’t. In most cases, they rely on wound care provided by home health agencies, which typically receive their orders from Physicians who are primary care providers and not experienced in the treatment and management of wounds.

The Frustration

  Home health nurses with knowledge of advanced wound care can become frustrated by having to accept orders for two to three times daily wet to dry dressing changes from a Physician who may not have assessed the patient at any recent time. As a result, a lack of real evidence based wound care is often the norm as to what is provided for homebound patients.

  These scenarios illustrate the need to examine the current methods of wound care delivery. Hospital based wound care centers may serve as the focal point for advanced wound care, but they serve only one aspect in patient’s need for a continuum of care. What happens to the patients who cannot make it to the wound center each week, or multiple times per week for hyperbaric treatments? What happens to patients who become hospitalized or need in patient rehabilitation? How can the appropriate wound care be provided when the patient is “out of your hands”?

The Program

  Wound Care on Wheels is a community outreach program created to provide quality, accessible wound management services to community members who do not currently have access to these services.

  The first part of the program is to provide wound management services to the homebound residents of the Greater Jacksonville area. Our Nurse Practitioner goes out to patient homes, Assisted Living Facilities, Nursing Homes, etc. to provide home wound management services. She works with existing home health agencies to coordinate the wound treatment plan of care and also serves as a consultant to Home Health Agencies and physicians to coordinate home wound management services and many times to make referrals to other specialists such as vascular or infectious disease.

  The second part of the program is the development of a 30-foot bus, which is designed to serve as a medical office for the treatment of wounds.

The Beginning

  Wound Care on Wheels, LLC evolved from a freestanding wound center, the First Coast Diabetic Foot and Wound Management Center, in Jacksonville, Florida, approximately 3 years ago. Our service has grown in response to some of the questions and scenarios raised as we have found a real need and have attempted to “fill it”. We provide wound care services in all relevant settings with the exception of hospital based wound centers. As a result, we are a referral-based service with our patients coming from multiple sources, including home health, physicians and facilities. We also provide services to patients in our freestanding wound clinic as we have for the past 10 years.

The Model

  This model allows for the continuity of care that has resulted in improved outcomes and better control of the delivery of care to our patients. As our practice has grown, we have become a true multi-disciplinary practice with services provided by Podiatry and Nurse Practitioners, all under the medical direction of an Internist. We work closely with other specialists not affiliated with our practice, who nevertheless enable us to provide the team approach necessary in advanced wound management. We refer to the appropriate specialists where needed, including vascular and endovascular specialists, infectious disease, nephrology and endocrinology to name a few. We also work closely with home health agencies to ensure that patients who require home skilled nursing visits will continue to do so.

The Challenges

  A tremendous amount of coordination of care, then, is required to address the numerous issues seen in our patient population. Communication is essential between attending Physicians, case managers, consulting physicians, home health agencies, and especially with patients and their families. Working around dialysis schedules and coordinating visits between home health services are two examples of frequent issues encountered.

  Comprehension of our service has been a challenge. Patients do not always comprehend that Physicians and Nurse Practitioners can and are willing to provide home wound management services. Once accepting, most are extremely pleased to know that help is coming to them. Many have expressed their gratitude.

  Payors do not always understand the rationale for our services and may question why a patient was seen in the home versus a wound center or clinic. The money saved on transportation to a wound center in cases where public transportation or an ambulance would be required makes economic sense for patient and payor alike.

The Benefits

  Physicians who serve as the patient’s primary care provider are usually pleased to have our Wound Specialists assessing and providing care to their patients. Communicating progress or deterioration of the patient’s condition to the Primary Care Physician has enabled us to further educate other providers regarding issues pertaining to wound management as well. We have seen numerous occasions where our service has recognized the need to have patients admitted to a hospital, whether the condition was related to the patient’s wound or not. This further decreases the liability of the Primary Care Physician.

  From a Provider’s standpoint, the area that stands out most in our experience over the last several years is really the “X factor” in wound care. That is, seeing how patients live and function in a home environment can explain much regarding why some wounds heal and others do not. Observing firsthand whether patients are taking prescribed medications, their food choices, compliance with recommended treatments, and overall living conditions are factors that may be assessed during home visits. These factors otherwise would be unknown when services are only provided in a wound clinic or office setting.

  Given a number of factors, we foresee continued and a growing demand for the services of Wound Care Wheels, LLC and other wound care services that provide mobile wound management services. Considering the ever increasing number of aging “baby boomers,” diabetics, and a healthcare system that discourages hospitalization of any duration, the re-birth of house calls in the form of a specialized comprehensive wound management service makes more sense than ever.

  Desmond P. Bell, Jr., DPM, CWS, FACCWS is the CEO of First Coast Diabetic Foot and Wound Management Center and Wound Care on Wheels, Jacksonville, Florida. He is also the founder and director of Wound Summit Outreach, Inc., the Southeastern Interactive Wound Summit, the Wound Care Consortium of Jacksonville, and the “Save a Leg, Save a Life,” Foundation. Dr. Bell may be reached at drbell@wounddr.com or at drbell@savealegsavealife.com.