Wound Care Silo Busting: Building a Service Line Across the Continuum

  Initially, wound care was thought to be the exclusive purview of surgical specialists. However, the involvement of physicians trained in family or internal medicine has brought another perspective to the field. These generalists and medicine specialists offer expertise in both diagnosis in the context of the whole patient and all the factors that may be impairing a patient’s wound healing. Due to this evolution, leadership has shifted in many places from nursing- to physician-led services, sometimes causing friction among healthcare arenas. Yet, with collegial relationships and common goals, involvement by multiple types of practitioners provides a great opportunity to consolidate expertise from each healthcare specialty and to centralize the care for each patient.

  Likewise, concepts such as the formation of accountable care organizations (ACOs) that streamline care based on measurable standards are becoming proven ways to improve efficiency, quality, and costs. Wound care, as an industry that involves multiple medical and nonmedical specialists who in many instances possess advanced training and education, provides an excellent framework to serve as a “hub” for the development of these types of comprehensive, collaborative service lines.

  This author, as the director of wound care services at Spartanburg Regional Medical Center (SRMC), a healthcare system based in upstate South Carolina, has helped lead an initiative to unite multiple departments of patient care services within the outpatient wound clinic in an attempt to enhance the patient’s experience throughout the continuum while improving clinical outcomes. This journey has been centralized on the success of the outpatient center, and services have grown from there. The vision to create continuous care across the system only really started to crystallize once programs on both the inpatient and outpatient sides had evolved and begun direct involvement with physical therapy (PT).

  This article will outline the steps taken by the wound clinic and health system as a whole to create a service line that functions much like an ACO without officially being recognized as one.

Defining A Need

  The manner in which healthcare delivery has evolved in sophistication while also becoming more specialized, subspecialized, and, thereby, fragmented in a sense is not much different than the way the facilities that house many service lines have changed over the years. Physically, larger hospital systems have grown piece by piece and department by department. Although many of us who work within a large network are literally connected by a series of tunnels and walkways, the reality is that many of our patients who require a combination of inpatient and outpatient services (or even just multiple outpatient services) may find themselves dependent on a cumbersome care continuum as connected as healthcare may appear to be on a global scale. This can lead to less efficient, lower-quality, and more costly care overall.

  The wound care services featured within SRMC, a 500-bed, Level I trauma center with an affiliated 48-bed community hospital about 20 minutes from main campus, include an outpatient department (HOPD), an inpatient wound team, an affiliated long-term acute care hospital (LTACH), inpatient hospice, and home health services. Much of the specialty and primary care for SRMC patients is provided by physicians employed by a network closely aligned with the main healthcare system that shares an electronic health record (EHR). Although this major “building block” had been in place to effectively consolidate and communicate among services, several key factors were still needed in order to create a fully functional and collaborative service line. These factors not only included an updated EHR to span both outpatient and inpatient arenas, but a system that could handle wound-specific data mining as well. Yet, the earliest requirements were actually much more basic. Identifying the “who, what, where, when, and how” of wound care — as in who cares for wound patients, where does wound care occur, how should previously disconnected services and treatment areas be joined, who should lead this effort on clinical and administrative levels, and how should this be structured? What follows is a step-by-step guide that explains how attempts to structure healthcare services around the HOPD took place.

Step 1: Identify Your Leaders

  Identifying leaders is probably the most important step for influencing growth in any clinical department. This is particularly true if you want to grow and then connect that area to others within a care network. At SRMC, wound care began as a partnership between an enterprising surgical group and a receptive hospital administration with services housed in an outpatient space within a building bridged to the main hospital. In 2003, the administration recruited the author (an infectious disease specialist with a degree in the immunology of infectious diseases) to serve as medical director of the HOPD.

  Relationships with several medical and surgical specialties within the inpatient arena and, to a lesser extent, the outpatient community, began to take shape. While the surgical practice had developed many relationships within the community, other surgical practices were reluctant to make referrals for what they considered then to be a lateral move.

  Having a non-surgeon lead the clinic seemed to shift the entire paradigm and allowed other surgical practices to view the HOPD as something other than “competition.”

  Services became specialized for wound care from the standpoint of physicians’ clinical focus to nurse training and competencies for technicians specializing in casting. As the HOPD’s operations, standards of practice, and, consequently, potential were dissected and analyzed, further diversification would soon be needed to help broaden the referral base and reach more patients earlier in their treatment courses.

  By 2014, the physician staff within the HOPD included a general surgeon (with 20 years of experience in wound care), two infectious disease physicians, two physician specialists in family medicine, and one internist.

  Nursing leadership was also vital to growth. The HOPD’s first nurse manager, Kim Saunders, RN, WOCN was hired in 2005. She possesses a broad range of nursing experience, a passion for learning, and a well-grounded work ethic. With the author, Saunders helped design guidelines for care to standardize the approach taken to the main classes of wounds (diabetic, venous stasis, arterial, pressure, and traumatic) and, among other quality initiatives, helped introduce the ankle-brachial index as a vital sign for patients and for organizing competencies for nursing staff.

  During this time, an inpatient wound team was also developed. The hospital’s original inpatient wound care team had been created with two wound, ostomy continence nurses (WOCNs) and the outpatient clinic medical director (for clinical oversight). As the inpatient team continued to grow, Saunders moved over to provide separate nursing management. Eight WOCN-trained nurses now staff the main hospital, community hospital, home care services, and LTACH. While outpatient care was physician-directed, inpatient care continued to be directed by nursing with clinical and administrative support from the medical director of system-wide wound services. Physician support is also available for the inpatient team by an outpatient wound physician staff for more complex patients or issues requiring a physician liaison.

Step 2: Identify Departments Providing Wound Care

  Throughout SRMC, multiple disparate departments had been providing some kind of wound care service. In fact, home health and floor nurses were often left to make wound care decisions for physicians — some of whom lacked the expertise to do so, but whose signatures were required on all orders.

  Additionally, PTs often provided advanced management within their own department while sometimes rendering redundant services with the assistance of nursing and some physician-run areas. SRMC’s wound care and hyperbarics center had opened in 1991 as a joint venture between a local private surgical practice and the hospital. While wound care was administered throughout the system, there were no common goals, no common vision, and no communication or opportunities for quality assessment. After identification of the various departments and practitioners providing wound care, partnerships then needed to be developed so that each discipline’s skill set and deficits could be understood and a streamline of services and supplies could be provided.

Step 3: Create Provider Partnerships

  Once departments and providers in wound care were identified, they needed to be connected to work toward a common goal. PTs, while loosely under the direction of physicians, often have a lot of independence in how they manage patients, unless directed by a physiatrist (of which there are none in this system involved with wound care). Advanced practice nurses (APNs) and, in particular, WOCNs also work fairly independently, owning a skill set that differs in many ways from the physicians with whom they work. On the inpatient side, admitting physicians, knowing little about wound care, would often pass off the entire responsibility for all things wound related to these nurses despite still having to be the final word in documentation and orders in the chart. At SRMC, the leadership role of the physicians differs depending upon where patients are being seen. In the outpatient arena, physicians lead the care plan. APNs are not staffed at this time in the outpatient setting, but the nurses are responsible for clinical wound assessments on patients coming in for assessments and dressing changes between physician visits. In contrast, the inpatient team is comprised exclusively of WOCNs.

  While still fairly independent, there is wound-physician oversight. Initially, the author and the general surgeon from the wound center were the two attending physicians available to see consults considered more complex or in need of more advanced diagnostic or surgical care than the inpatient team could provide. SRMC is currently in the process of training another wound physician to attend on the inpatient side.

  On the PT side, efforts to forge these partnerships paid off and the original administrative vision to bring PT services and wound care together has been realized. Not only do PTs now work in the wound center, providing advanced-care services such as low-frequency ultrasound, electrical stimulation (e-stim), and whirlpool as well as mobility/seating assessments, they have provided physicians with education in many of these services that otherwise would not have been exposed. Another outgrowth has been an expansion of casting services. Full-time technicians specifically responsible for wound care-related castings were hired in 2008 and this program has expanded to techs providing a variety of offloading casts.

  Partnerships have also been created among physician specialties. As part of the larger plan to create a multidisciplinary team, administration has been lobbied by physicians to hire a plastic surgeon. Initially, that surgeon was given hours in the HOPD. This cemented a relationship and, again, helped staff understand the value of each specialty’s skill set for patients. While plastic surgery does not still have clinic time in the wound center, that relationship has held strong.

  The experience with vascular has been similar. Initially, one of the hospital’s surgeons interested particularly in revascularization of the lower limb was invited to the HOPD. He, too, came to the center and saw consults. Ultimately, his clinic time was eliminated, but again a relationship was cemented.

  The decision to no longer have both plastics and vascular surgery in the outpatient clinic was made between the HOPD and the surgeons because it was determined more efficient to use clinic time for general wound patients and to refer those patients necessary to their offices nearby.

  Partnerships with other hospital areas such as the emergency department (ED), where discussions related to process improvement have aided the referral process, have also been vital to improving continuity of care. Inpatient admissions from the wound center have also been improved through communication and standardization. Examples include continuing discussions with endocrinology and the network of primary care providers. As these partnerships continue, SRMC also continues to refine its processes.

Step 4: Allow Administrative Structure to Evolve

  Growth in services requires growth in leadership structure, and both the outpatient and inpatient departments required restructuring in order to form a centralized service line. Because growth happened around a centralized idea, the expansion of a new administrative structure has occurred from a single purpose rather than with parallel or — worse — divergent evolution in multiple departments. At SRMC, the inpatient wound team now has its own manager while Saunders has ascended to nursing director of a new “wound services” department (a new nursing division encompassing the HOPD, inpatient wound services, and those services extending to home health, hospice, and LTACH).   This was an idea conceived as a parallel structure to the medical director of wound services (Figure 1). The inpatient team and HOPD staff individual nurse managers whose needs are bridged by Saunders. In addition to the evolvement of nursing leadership, physician leadership has also been adapted to include a separate director for hyperbaric services — Melissa Fritsche, MD.

  This has led to more structure and attention to these services, credentialing by the Undersea and Hyperbaric Medical Society, refinement of safety protocols, established standards of practice, and structured quality measurement metrics. While continued administrative growth on the physician side is expected, this has been a slower process as most physician leaders still retain heavy clinical responsibilities. Regardless, having both physician and nursing “champions” work together has been necessary to liaise among administration, medical, nursing, and PT staffs and to communicate consistent messages across the system. This has been very effective to gaining administrative and collegial support for the agenda to streamline care.

  As growth prompted expansion of leadership, strong leadership has supported continued expansion. Ultimately, this balanced approach has resulted in effective centralization of inpatient and home health services with staffing, quality reporting, and supply management. For example, supplies are now standardized for wound care across all areas including inpatient, outpatient, LTACH, and home health. While there may be slight variations in some product purchasing, wound supply purchases are now system-wide and vetted by leadership in wound care.

Step 5: Bringing Components Together

  Efforts to provide system-wide continuous care began when administration brought PT, nursing, and physician services together under the same roof, literally, in the same HOPD. The original intent of this was to bring PT, which can typically fall into a bit of a “silo” in the nurse/doctor-dominant care environment, into wound services.

  Collaborative decisions on which modalities are worth maintaining for our patients are now the standard. For example, mobility and seating assessment are still under PT administration, but are also an integral part of the pathway to care among paraplegic and pressure ulcer patients. Other PT services, such as e-stim, whirlpool, and ultrasound, are physically located in the HOPD. PTs have also been more involved with compression wrapping, and should the often medically complex wound patients have an acute condition they can be seen immediately by a physician rather than having to go to the ED or be transported to another clinic for evaluation.”

  Having a defined team of leaders overseeing both inpatient and outpatient clinical services has also helped troubleshoot “gaps” in care. Issues that have been addressed have include critically evaluating continuity of care of the patient who has required flap closure of a wound, care of the paraplegic patient in general, continuity in offloading, surgical and infectious disease management for patients living with diabetic foot ulcers, and continuity of care for patients requiring vascular evaluation or compression wrapping both in and out of the hospital.

  In general, one major obstacle experienced had been the lack of successfully implementing an outpatient wound treatment plan prior to discharge of inpatients. Previously, the inpatient team would see the patient and on discharge there would be a delay in wound physician assessment and creation of an outpatient plan of care. This had caused confusion of who was responsible for home health wound orders, often resulted in lack of appropriate offloading for a period before the outpatient appointment, and overall exposed the patient to complications due to lack of continuity. For paraplegic patients, this would also include sequencing seating evaluations before going in for a flap to attempt to obtain an appropriate cushion for when they healed following surgery.

  Now, for example, the diabetic patient living with a neuropathic foot ulcer can get casted prior to discharge so that appropriate offloading could start immediately rather than having to wait for the outpatient wound physician to evaluate. Similarly, patients living with pressure ulcers in need of elective flap closure now get their seating evaluations and cushions or wheelchairs ordered prior to going in for surgery so that they don’t return to sitting on the same chairs and cushions on which they developed ulcers.

Step 6: Evaluate Communication

  Nothing can replace the benefits of effective communication to bind patient care throughout the health system. Person-to-person communication is the mainstay that ultimately is the focus of this system-wide network.

  Daily rounding calls help providers identify patients from the HOPD center who have transitioned to inpatient care and vice versa. This helps to identify patients who may require physician-level input as part of the inpatient wound team’s effort. While often difficult to incorporate into busy clinical schedules, monthly meetings have been an important opportunity for communication. Physicians and other providers must buy into this. Without participation, one cannot expect the exchange of ideas.

  SRMC also utilizes a post-acute care wound committee that includes members from PT, LTACH, home health, hospice services, and wound service clinical directors (from nursing and the clinical medical director). The current EHR provides a way for inpatient and outpatient teams to follow each patient throughout the continuum. While the EHR is not part of the inpatient documentation system for the hospital, it can be accessed from all hospital computers and outpatient arenas.

Evolving Assessment

  Since consolidating services, SRMC is now in a position to get much more reliable data related to quality of care throughout the system as well as in individual disposition areas to establish and assess metrics.

  Through a detailed review of system services, consolidation, communication, and consistent leadership the creation of a functional service line through wound care has been implemented. Partnership development with administration as well as all clinical areas where wound care is provided has been essential to unifying this system. Moving forward, continued expansion of services and referrals is anticipated. Wound care’s relevance throughout the healthcare system puts SRMC in a perfect position to improve continuity, efficiency, and quality of care. Debra Miller-Cox is an infectious disease specialist in the immunology of infectious diseases and is director of wound services at Spartanburg (SC) Regional Healthcare System.