Wound Care on the Go

  There are few images more associated with the nostalgic, bygone era of medicine than a physician making “house calls” throughout a community. Presently, the theory of “patient centeredness” has become a cornerstone of modern healthcare reform. A system that once was completely focused on “what was best for the patient” is now completely aimed at doing what is “financially best for the physician and the business of private and government-run insurance companies.” However, our current medical practice known as Physician House Calls using our Community-Based Portable ER (Portable ER) represents a transition back to excellence in which medical and surgical (med/surg) services such as advanced wound care can be conveniently performed in any setting, but are particularly valuable in rural and suburban communities. Through this proven method of care, healthcare providers can combine old-fashioned home visits with modern medical technology to achieve patient-centered advanced wound care with substantial insurance reimbursement. Our private practice provides expert med/surg care for patients living with most wound care issues, including pressure ulcers; arterial and/or venous-insufficiency ulcers; diabetic or neuropathic ulcers; skin tears, abrasions and avulsions; simple, complicated, and complex lacerations; and thermal or chemical burns. This article will discuss the development and concepts of the Portable ER and how it relates to improved mobile wound care outcomes and business.

History of the Portable ER

  The Portable ER,^1,2 which is noted for its use in offering advanced wound care, was successfully implemented in the U.S. (in the Greater East Aurora Area of Western New York State) on Feb. 16, 2009. While home health agencies provide non-surgical patient care to patients who meet the requirements of homebound status, the Portable ER allows physicians to make house calls to provide med/surg services such as mobile wound care to patients who do not qualify for home health agency care and/or who may be lacking adequate transportation, finances, insurance, and/or family support (or a private primary care physician). After leaving the military in 1990, I redeveloped and expanded the usage of a Portable ER system I had developed for the US Navy to provide better med/surg care to civilians during missionary international emergency-medicine trips. The civilian Portable ER was redesigned, tested, and evaluated to best care for patients during and recovering from natural disasters and the devastating results of terrorism and anarchy. In my current position as the medical and scientific director of Saved by Grace Ministry Inc. (East Aurora, NY), serving since 1998 along with my wife and co-founder Janice E. Sterba, I use the Portable ER for the private medical practice of emergency medicine and urgent care medicine, including advanced wound care.

Making The Physician House Call

  When a phoned-in request for physician services is made, each patient is triaged for appropriateness. More often than not, rapidly determining the chief complaint and history of present illness (HPI) during the call determines whether an onsite visit is appropriate within about four minutes’ time. Occasionally, certain requests lead to a referral to a primary care provider (PCP), other med/surg specialist, or local therapist (eg, when a request for general child vaccination is made or if a physician referral is specifically requested). A growing request is actually for us to become a PCP with no current chief complaint, in which case patients are referred to local PCPs accepting new patients. Approximately 5-10 percent of our phoned-in requests are true med/surg emergencies. These complaints are quickly and expertly triaged, and patients are instructed to call 911.   Upon accepting a patient’s request for a house call, the physician selects the needed hand-carried med/surg kits and portable dispensary cabinets (PDCs) among the 87 within the Portable ER dispensary and travels in a mid-sized, fuel-efficient car to the home. All kits and PDCs are stored securely in a private residence that’s humidity and temperature-controlled. (For Portable ER inventory, see references^1,2 and sidebar on page 21).   Assessment of nutritional considerations such as body mass index, ideal body weight, and skin fold thickness are quickly determined during a house call. These indices help identify protein/calorie malnourishment in patients living with slow-healing wounds and prompt better nutritional recommendations and more successful follow-up care. The Portable ER also provides blood-chemistry services. Total serum protein and albumin can be measured and printed by a portable point-of-care POC lab using the Centers for Medicare & Medicaid Services’ (CMS) Clinical Laboratory Improvement Amendments-Waived Comprehensive Metabolic Profile (CMP) panel. Nutritional assessment with printed CMP lab results can be obtained and explained in fewer than 15 minutes during a house call. From our ongoing Institutional Review Board-approved clinical study that measures patient convenience of house calls, the time from ordering a blood chemistry test until lab results are explained is 13.8 minutes. (+ 5.2 minutes. SD, n = 45 patients). Two sensitive blood chemistry tests (pre-albumin and serum transferrin) that are useful to assess current nutritional status must be drawn at the home and taken to a lab.

Finances of Physician House Calls

  Our private medical practice is credentialed as a humanitarian, public charity, nonprofit corporation. Tax-deductible donations are accepted and contributions, insurance-required co-pays, and insurance checks are used to help care for other patients in great need in our community and to buy med/surg supplies or medications. Patients without insurance are never turned away — donations are encouraged in these instances. In addition, Saved By Grace Ministry Inc. has provided med/surg care to more than 4,300 patients during seven civilian medical missions from 2004-08, settings in and out of hospitals in West Africa,6 Central America, and the Caribbean Basin.^7,8   Our insurance billing is approximately 25 percent of the cost for similar services billed from the hospital-based ED. Of all patients seen during house calls, 91 percent are not clinically indicated to be sent to the ED. The remaining nine percent require to be transported to the ED for further lab/radiology studies, but are rarely admitted.   The most productive and economical way we recruit patients is through inexpensive advertisements printed in local newspapers that are often clipped and saved by patients in the event of needed care. Some people have actually made “referrals” by seeing our ads. Likewise, we’ve produced refrigerator magnets and business cards, which are freely passed along after house calls as well as during community events such as health fairs, festivals, and parades. A brochure that lists all portable med/surg services and POC laboratory services has been mass-produced using an at-home publishing program and shared throughout the local community, and has been warmly received by local pharmacies, private physician offices, laboratories, nursing homes, businesses, and churches. We also frequently provide demonstrations at community service organizations and events such as Kiwanis and Lions clubs and senior citizen centers. Furthermore, we provide hands-on training through inservices that fully equip interested healthcare providers to establish their own portable services.   By providing house calls, the Portable ER has decreased inappropriate overuse of the local ED and has grown financially through the enthusiastic endorsement from patients and family members as well as through support from area physicians (including primary care, emergency, and med/surg specialists on staff at local hospitals), insurance companies, Medicare, and Medicaid. Additionally, local church, civic leader, and public support have been very strong.^9-16 CMS allows reimbursement for “home visits” wherever a patient may live, including in the private home (Place of Service [POS] 12), temporary lodging (POS 16), nursing facility (POS 32), skilled nursing facility (POS 31), and homeless shelters (POS 04). Since patients are not seen or treated at a physician’s office, commercial zoning is not needed for physicians to conduct house calls. General liability insurance is also not needed by the physician because the Portable ER is not a “mobile clinic.” Patients are not treated inside a vehicle, obviating the need for related insurance or licensing typically required by the department of health. However, physicians must maintain their own medical liability insurance policy for their specialty. (Part-time practitioners, ie fewer than 20 hours per week of actual patient contact time who don’t perform acute care, see lower premiums.)   Recently, we successfully petitioned and were advised that National Government Services Medicare B will begin paying for all integumentary procedures, including surgical debridement and other procedures for physician house calls that are conducted in a patient’s private home or temporary residence. Our advanced wound care during house calls is documented on paper and electronically. In conclusion, Physician House Calls using the Community-Based Portable ER provides faster, better, and cheaper care — including advanced wound care — when compared to the hospital-based ED or urgent care facility. John A. Sterba can be reached at 716-655-6854 or physicianhousecalls@roadrunner.com. For more information, visit www.physicianhousecalls.org. Caroline Fife, MD, FAAFP, CWS contributed to this article.

What’s in a Portable Wound Care Kit?

  Dr. John Sterba’s wound care dispensary features a wealth of items used for the treatment of wound care patients. Listed below are the contents of a med/surg kit indicated for “advanced wound care for chronic or acute wounds: pressure ulcers, venous stasis ulcers, arterial insufficiency ulcers, DM/neuropathic ulcers, burns, skin tears, severe abrasions.     a. Irrigation: Modified Dakin Solution; Normal Saline     b.Wound Cleanser: Restore, Skintegrity     c. Skin Cleanser & Moisturizer: Restore     d. Dimethicone Skin Protectant/Sealant: Restore DimethiCreme, Skin Prep, Sureprep     e. Transparent Adhesive Film: OpSiteTM, TegadermTM     f. Hydrogel: ClearSite®, FlexigelTM, Restore Gel/Pad/Strip     g. Contact Layer: Restore Contact Layer Dressings With TRIACT Technology, Restore Contact Layer-Ag With TRIACT Technology, Restore DUO Absorbent, Restore TRIO Absorbent With Adhesive     h. Hydrocolloid: DuoDerm®, RepliCare®, Restore Extra Thin Hydrocolloid Dressing     i. Medihoney® and Honeycolloid     j. Collagen Matrix Dressings: BiostepTM     k. Collagenase Enzymatic Debridement: Santyl®     l. DM-Ulcers-Recombinant Human Growth Factor: Becaplermin (Regranex®)     m. Alginate: Silvasorb®, Sorbsan®, AlgiSiteTM, Medihoney® Ca-Alginate; Restore Calcium-Alginate Regular Dressing or Rope Dressing, Restore Calcium-Alginate with Silver (Ag) Regular Dressing or Rope Dressing     n. Polyurethane or Polyvinyl Alcohol (PVA) Foam Dressing: Allevyn®, Restore Lite Featuring TRIACT Advanced Technology, Restore With or Without Border, Restore Non-Adhesive With TRIACT Technology, Restore Hydro-Shield Without or With Border, Nu-Derm®     o. PVA Foam Dressing With Bacteriostatic Gentian Violet/Methylene Blue: Restore Hydroferra Blue® Bacteriostatic     p. PVA Foam Dressing With Bactericidal Silver (Ag): Allevyn®     q. Silver-Containing Barrier Dressing: Acticoat®, Silverlon®, Aquacel® Ag, Arglaes®, SilverCel®, SilvaSorb®, Flamazine     r. Silver-Containing Antibiotic Crème: Silvadene     s. Bacteriostatic/Autolytic Crème: Sulfamylon     t. Mupirocin 2% Antibiotic Crème/Ointment     u. Topical Antimicrobial, Bacteriocidal Barriers: IodoSorb, IodoFlex     v. Vacuum-Assisted Wound Care, Negative Pressure Wound Therapy     w. High-Pressure Wound Care Systems: VersaJetTM Hydrosurgery Wound Debridement.     x. Pressure Relief Surfaces: ROHO Seat Cushion.

References

1. Sterba JA, Sterba JE. Textbook of Equipping for Disasters, Sheltering at Home. Third Edition. Saved by Grace Ministry Inc. 2012. 2. Sterba JA, Sterba JE. Textbook of Equipping for Disasters, Sheltering at Home. Third Edition. (Kindle edition) Saved by Grace Ministry Inc. 2012. Published electronically by amazon.com for Kindle Books (eBooks) on June 30, 2012. www.amazon.com. 3. Sterba JA. Arctic cold weather medicine and ac¬cidental hypothermia. Navy Experimental Div¬ing Unit (Panama City, FL). Report 2-90. 1990. 4. Sterba JA. Thermal problems, prevention and treatment. In: Bennett PB, Elliott DA (Eds.). The Physiology and Medicine of Diving, Fourth Edition. W.B. Saunders Co., Ltd., London. 1993. 5. Sterba JA.Arctic cold weather medicine and accidental hypothermia. In: Underwater Construc¬tion Team Arctic Operations Manual, NAVFAC P-992. Naval Facilities Engineering Command, Alexandria VA. 6. Sterba JA. Kamakwie Wesleyan Hospital: an assessment of needs report. Center for Sports Therapy Research Inc, East Aurora, NY. 2004. 7. Sterba JA. Mission guide: Cachón and Barahona Province, Dominican Republic. Saved by Grace Ministry Inc., East Aurora, NY. 2006. 8. Sterba JA. Mission guide: Caribbean and Cen¬tral America. Saved by Grace Ministry Inc., East Aurora, NY. 2009. 9. Sterba provides in-home emergency medical care. East Aurora Advertiser. 2009. 10. Testimonial: Dr. John Sterba says PennySaver ad works. PennySaver. 2010. 11. EA’s Sterba makes old-fashioned house calls. East Aurora Bee. 2011. 12. Physician house calls provide free labs at home & at work. PennySaver. 2011. 13. Free point of care labs offered in East Aurora. Sterba can do blood tests onsite. East Aurora Advertiser. 2011. 14. Brodsky L. Healthcare Delivery Models are Changing - a New Model as Practiced by “Dr. John.”Accessed online at https://thebrodskyblog.com/?p=2623. 15. House call services is growing. Sterba offers care at home for local residents. East Aurora Advertiser. 2012. 16. Physician house calls: faster, better, and cheaper than your doctor (PA, NP) or urgent care or the over-crowded ER. East Aurora Advertiser. 2012.