Evolution of Wound Care Centers and Outpatient Infusion

  Wound care centers and programs are a fairly recent development. Previously, generations of physicians dealt with complicated issues such as wounds, infections, and multiple risk factors that led to peripheral vascular disease within their practices. As healthcare costs have escalated, so has specialization of care. Now, it seems specialization and compartmentalization of care has somewhat crippled our system. Patients are the unfortunate victims; they sometimes must see multiple specialists located in various facilities in order to maintain their health.   Take the typical middle-aged adult living with diabetes. Both microvascular and macrovascular disease develops in an infected foot, leading to a chronic wound and osteomyelitis. Typically, a primary care physician would attempt to treat this individual and, when necessary, provide referral to a podiatry, vascular surgery, infectious disease (ID), wound care, hyperbaric oxygen (HBO), and/or interventional radiology/cardiology specialist. In some instances, the patient is sent to a wound center and is hopeful that all his needs will be met, only to be sent to a surgery center and an infusion center before being directed to a radiology center. Further complicating matters, home health services is demanding the patient be homebound for most of his care.   In response, wound centers can consolidate services for wound, infusion, and hyperbaric therapy.

Out of the Loop

  Wound care and hyperbaric therapy often are integrated, but infusion service (ie, provision of IV antibiotics, IV hydrations, IV immunoglobulin [IVIG], and other biologicals [eg, infliximab] as part of a wound care center is still a novelty. Outpatient antimicrobial therapeutic (OPAT) centers have been evolving, transforming many outpatient programs.   The natural fit of wound care with infection treatment and hyperbaric oxygen therapy demands these collaborative services be tied together. Patients can visit one center, receive IV antibiotics and hyperbaric oxygen therapy, and have wounds debrided and dressed all in one sitting. This is practical for patients and provides fiscal incentives for the center. When a multidisciplinary service line is offered, the center benefits from the ability to maximize billing with minimal efforts, especially under an efficient electronic medical record. Oversight of these services can be directed under one medical director, one team or support system, and in one space, eliminating the high cost associated with multiple sites.

Where to Begin

  Centers that provide only wound care can expand to such an approach. Usually the limiting factors are space for clinic expansion and initiating an affiliation to be part of a hospital-based program. It is essential to have buy-in from multiple sources such as hospital administration and medical staff, as well as the interest of the surrounding community hospitals and specialists who will want to evolve the program into a center of excellence. The expanded-services wound center would remain under the direction of a physician and a program director. Sufficiently trained personnel, including an infusion-trained nurse, a wound/ostomy-certified nurse (WOCN) or a clinical wound nurse (CWN), and a hyperbaric technologist will broaden a center’s capabilities. Potential cross-training would enhance and consolidate personnel responsibilities. With many specialized nurses already providing home health and earning experience in infusion and wound care, it is not difficult to find cross-trained personnel. Under the supervision of a physician, training all personnel to multitask is feasible. Certification for both physicians and nurses in these specialized areas is complex and beyond the scope of this article, but may have important implications for compliance and billing. Allowing specialists such as surgeons, radiologists, podiatrists, and interventional cardiologists to see patients in the center would facilitate collaboration while reducing healthcare costs and the process of coordinating patient care among different providers. Many physician groups have become motivated to develop centers of excellence and enhance the reputation of their practices, allowing them to open new clinics without new overhead.

Caveats

  The need for an infusion center to provide care 24/7 could necessitate a change in the center’s hours. Options to collaborate with home health to provide infusions over the weekend could work, especially if the center is restricted to a weekday schedule. However, outpatient options for IV antibiotics are becoming more complicated because certain carriers demand OPATs remain the preferred providers of care. An example is Medicare’s reimbursement structure for IV antibiotics covering OPAT or skilled nursing facilities over home health services, especially with Medicare parts A and B. Additionally, home health pharmacy is restricted under Medicare Part D (prescription benefits). Unfortunately, using Part D for infusion services would quickly utilize prescription coverage that is capped for the fiscal year for the patient. This usually results in the patient paying the costs of other prescriptions out-of-pocket by the end of the year. Services need to be coordinated under an ID specialist, wound specialist, and HBO specialist. Traditionally, the ID specialist (not a pharmacist) provides OPAT. All services rendered in the hospital-based outpatient wound center are provided incident to the physician service. The billing and compliance rules that pertain to these activities are complex. Clinicians are encouraged to get expert advice as they contemplate expansion of services. Dr. Le is chief of staff of Loma Linda University of Murrieta and medical officer of Restorix Health.