A Vision for Enhancing Wound Clinics' Business Model

This author interviews Teri Biven PT, DPT, CWS, FACCWS, and Melissa Johnson PT, DPT, CWS, who explain how they developed successful wound/ulcer management provider-based departments (PBDs), how to manage across a continuum of care, and what you can learn from their business model.

Many years ago, this author had the opportunity to consult with Teri Biven, PT, DPT, CWS, FACCWS, and Melissa Johnson, PT, DPT, CWS, when they wanted to move their wound care services from physical therapy departments to multidisciplinary wound/ulcer management centers for excellence. They accomplished their goals and now manage multiple hospital owned outpatient provider-based departments in the Piedmont Health System.

Every year this author would learn about their progress when they, and many members of their team, would attend the Wound Clinic Business seminar where they would receive new reimbursement information as well as ideas for positioning their departments to manage wounds/ulcers throughout the continuum of care. When this author last spoke with Dr. Biven and Dr. Johnson, they described the exciting work they are doing to enhance their business model. Their vision and their work are so remarkable that this author asked their permission for an interview to share with Today’s Wound Clinic readers. They agreed with the hope that readers will get some ideas and become motivated to reposition their wound clinics for future success.

KS:     Both of you manage successful wound/ulcer management provider-based departments (PBDs). What gave you the idea that you should consider enhancing your business model?

TB/MJ:     I do not think this is unique to us by any means, but over the last 5–10 years, our patient population has grown overly complex and is much more acute than in previous years. With this shift, more of these complicated patients are now “shared” amongst PBDs, home care, skilled nursing facilities (SNFs), and other providers. These other care partners have varying degrees of knowledge about wound management, and widely varying skills. Many times, these complex patients return to the clinics due to a lack of staff or resources within the community to manage the increasing needs of caring for patients with such complex wounds. This identifies an opportunity for wound programs to join forces within the community to provide education, expert collaboration, and resources.  

As we forecast the needs of our growing community, the prospect of care diversity needs in our health care system, along with the mounting need for wound trained clinicians and providers, we have strategized to prepare and reach patients across the continuum of care. In speaking and learning from other health care experts about the trends in healthcare, specific to wound care, we have learned to view our work, and our future work, from a much broader perspective. That model resembles a shared risk model across many providers in the wound care realm.     

KS:     If you could wave a magic wand, what would be your “dream wound/ulcer management business model”?

TB/MJ:     The wound clinic model would look quite different than current state, in which we are still primarily “clinic-based” (meaning we are bringing patients to us). We would see a move to the “patient-home” model with trained resources in the community and other skilled resources in long-term care facilities. The clinic would be more of a “home base” for expert resources, who would be managing patients who require procedure-heavy processes during initial visits. Then once wound progression becomes more stable, these resources would transition patients to community-based resources for continued management, with the clinic reviewing care and progress peripherally but on a parallel timeline through an integrated electronic medical record (EMR). In this model we would collaborate via telemedicine to bring our expertly trained eyes to a larger care group, with more video or photo-interactive means, via apps, phones, et cetera, along with use of patient charting interfaces within our EMR. We would be partnering very closely with our population health team to work on wellness, prevention, and complex care. This capability would extend our services far beyond the walls of our clinic to better manage our community’s health across the continuum of care.  

KS:     Does your health system have all the necessary components to make your dream business model a reality?

TB/MJ:     We anticipate through strategic community partnerships to grow our current care spectrum with broader coverage to manage wound patients closer to their homes. We believe necessary components include staffing within our departments to support the model. In addition, relationships and collaboration with our community partners will be vital for success. This model does not present itself as a silo but more of a continued collaborative process throughout the various patient care settings.   

In the last year, and expedited tremendously with the pandemic, we have launched telemedicine across the system. This platform will play a noteworthy role in how we assist the other caregivers in our system. One of our continued barriers to care is the lack of available home care options for our current patient population. Staffing challenges and reduced resources in the community have caused patients to revert into the clinics for management, and often and much worse, rebound back for hospital readmissions. These staffing challenges impact us as well, limiting our ability to be integrative in our approach to care with our community partners.  

Even as we are part of a growing health care system, these opportunities exist for smaller, individual hospitals as well, and may even be easier to accomplish without the confines of a larger system. It is imperative to reach out to all potential care partners within your area to begin to establish working relationships to collaborate on these complex patients.

KS:     A project of this magnitude does not sound like it can happen overnight. Do you expect to revise your business model in phases?

TB/MJ:    Yes, we frequently revisit and revise our plans. Moving forward, we anticipate a much greater project management aspect to our roles due to the many different care interfaces that are needed for this growing wound patient community.  

System processes and standardization will be key to success when approaching this model. The growing market share of our system will give us a greater advantage to reach larger populations, give us purchasing power, and influence payor sources in the future. However, even though our vision is from a large system perspective, it does not mean this cannot be accomplished on a smaller level. We encourage all in the wound care field to begin this work, no matter how large or small your organization. Institutions of any size can implement a similar business model. You must remember that it will “take a village,” including administrators, providers, other ancillary departments, and community partners, to align with common goals and outcomes of this new wound care model.  

KS:         Have you begun any of the work? If so, where did you begin?

TB/MJ:     Understanding reimbursement and payor changes are vital to keep in the forefront of decision making to ensure the model is profitable financially and to maintain viability for the future. We have relied on your monthly wound care columns and the Wound Clinic Business seminars to assist us with the trends and potential pitfalls.  

Being on a single electronic medical record (EMR) was a significant step to creating standard work across all hospitals. This was a critical phase for us and recently we brought all our clinics to one EMR system that we created and built for over a year and a half. This EMR is our hospital standard and is utilized across various other settings which improves communication between providers and ultimately improves patient safety and care. This may be much easier in a smaller hospital system without several disparate systems in play.

Formulary standardization is key to maintain standard work regarding protocols and treatment options. Variability in formulary makes it hard to remain consistent across the care settings. This has been an ongoing project with all our hospitals being in different phases of acquisition and onboarding. We know we have a lot of opportunities for consolidating products, processes, education, and resources. As stated above a smaller system may have a far easier time standardizing formularies in use.

Investing in knowledgeable clinicians, including physicians, mid-level practitioners, physical therapists, and nurses, is vital to program success. Recruitment and retention of staff can be difficult during these times and having recruitment efforts to hire those that fit into our business model will have a huge impact on future progress.

Additionally, training and education is and will continue to be a large component of our project. We will continue with training staff at many different levels. In the last few years, we have implemented the Wound Treatment Associate (WTA) Program™ and wish to continue this for ongoing training of staff for all care settings within our healthcare system.  So far, we have trained over 100 staff with this program; those staff include LPNs, RNs, PTs, OTs and even some nursing assistants. (The WTA program is a 12-week course in wound care skills developed by the Wound, Ostomy and Continence Nurses Society to meet the growing needs for skilled wound care providers.) For smaller or single entities, offering educational opportunities within your own institution and in the community will expand your ability to work together. Other options that will improve collaboration include sponsoring or hosting educational opportunities for your community partners. Utilizing your expertise and knowledge to improve care across the continuum benefits everyone including the patients.

Furthermore, we have worked very closely with a local university in Atlanta (Mercer University) to bring their doctoral physical therapy students in for clinical rotations, which has increased our exposure to new graduate physical therapists within the community to the role of physical therapy in wound care. We are working with them on several research studies and anticipate a wound care residency program to launch in the next couple of years. This is another example of a partnership that can enhance future recruitment efforts.

KS:     As you reflect on the hard work you have done to create all the successful PBDs in your health system, are you particularly thankful that you spent time refining certain parts of your existing PBDs? If so, what parts of your existing business model will make it easier to achieve an enhanced business model?

TB/MJ:     As previously mentioned, we recently transitioned to the same EMR. Now that we are using a single EMR, we are working to create clinic benchmarks with department reports and metrics. At times it feels like we are taking a step back, but we know it is imperative to use the same medical record system.  

We have employed more providers, advanced practice practitioners and clinicians over the past few years and these providers are seeking to implement more standard work, with treatment algorithms and guidelines so all sites are performing standard work across all clinics. Our hospital system has implemented a clinical shared governance model for standardizing best practices, and this group is now forming to work on these standards.

With this provider employment we recently aligned our credentialing criteria for all wound providers working in our wound departments across the system. This differentiates our care above other clinics by requiring advanced certifications and thus we anticipate overall improved outcomes.

KS:     Are you anticipating any particular stumbling blocks to enhancing your business model?

TB/MJ:     Actually, we have had some growing pains—balancing the priorities with new markets against our own organic growth. In the last few years several of our hospitals have had expansions of new hospital units and new towers, requiring additional staffing and education within our own teams.

To successfully make this new business model a reality, we must continue to socialize the need for change to those that can make and support decisions. Lack of knowledge, regarding wound care and its complexities, will continue to be a stumbling block during this project. It is our responsibility to continually gather and share information and data to achieve “buy-in” from those who make higher level decisions. Learning the structure of our own institution and the community we serve was one of the keys to refining our wound care business model.

KS:     What advice would you like to share with other wound/ulcer management professionals who understand they should enhance their current business models?

TB/MJ:   If we have learned anything in this process, it is to be agile and to continually iterate all processes. You should continue to learn from experts and to collaborate with your partners. In addition, you should Identify the needs of your population and what resources are available outside of your hospital, look to collaborate, and share knowledge to better manage patients across the continuum.

Maneuvering through the challenges of reimbursement and changing payor rules should be a constant part of our jobs. Keeping up to date and identifying the best opportunities for financial profitability should always be in the forefront of decisions. Collaborating with groups that can support and drive change within your institutions will be important along the way.

In addition, wound care often appears to be a small ancillary department in the eyes of many decision makers. Do not sell yourselves short. Remember that your service touches every major hospital system service line and specialty, from the neonatal intensive care unit to psychiatry. Continue to preach this to all who will listen. Make a goal of educating your hospital system about your roles. Partner with pertinent hospital teams, such as risk management, revenue cycle, compliance, and quality departments. Partner with pertinent clinical teams to share your unique value and skill set that impacts your caregivers, patients, and community.  

Continue to educate yourself on the various aspects of practice, new upcoming treatments and trends related to wound care. Then create a niche where you and your skills fit. Do not rely on others to know your practice because it is your responsibility to promote your service line and what it means to the community at large.

Chronic wounds cost millions of dollars to our system and payors over a patient’s lifetime. We have been in a reactionary mode of treating these complex wounds for so long but imagine if we can catch them early before they become a worsening problem, or better yet prevent those wounds from developing. By shifting our care model toward more prevention and wellness, and by remaining persistent in our mission to create this cooperative approach across the continuum of care, it will return our investment in spades. It will be worth all our efforts to see our vision really come to fruition.

Lastly, engage with leaders at all levels and promote your skills to them. It takes a village, and that village will advance you to the next level.

KS:     Thank you, Dr. Biven and Dr. Johnson. The readers will surely be motivated by your vision and your work.

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Teri Biven, PT, DPT, CWS, FACCWS, has over 28 years of experience in the field spanning across multiple practice settings, and currently is the Manager of Wound Care and Hyperbaric Medicine services at Piedmont Atlanta Hospital, where she began working in 2000. Dr. Biven is a founding member of the Piedmont Healthcare Wound Care "STARs" group responsible for the delivery and integration of high-quality wound care services and hyperbaric medicine for the Wound Care Collaborative within the Piedmont system. She is a longtime member of the American Physical Therapy Association, a section member of the Clinical Electrophysiology and Wound Management Special Interest Group, and a member of the Specialization Academy of Content Expert. She holds an adjunct clinical assistant professorship in the Department of Physical Therapy of Mercer University College of Health Professionals. Dr. Biven has been a Certified Wound Specialist through the American Board of Wound Management since 2003, and a Fellow of the American College of Clinical Wound Specialists since 2008.

Melissa Johnson, PT, DPT, CWS, has over 21 years of experience in all settings of practice performing wound management, specifically acute care, and outpatient physical therapy since 2000. Since 2006 she has worked for Piedmont Healthcare as the Director of Wound Care and Hyperbaric Services for various hospitals within the system. Dr. Johnson sits on multiple system leadership committees that enhance quality and standardization within the Piedmont System. She is a Certified Wound Specialists through the American Board of Wound Management since 2004. She has held various leadership positions within the ACEWM and Wound Management Special Interest Group of the American Physical Therapy Association where she advocates for wound care practice. She is currently the Chair for the Wound Management Special Interest group for the Academy of Clinical Electrophysiology and Wound Management for APTA. Over the past 10 years she participated on the task force for the development of a clinical specialty of wound management approved by the American Board of Physical Therapy Specialists in 2019. She has been an adjunct professor at Nova Southeastern University since 2009. Currently she is a member of the Alliance of Wound Care Stakeholders and Federal Affairs Liaison for the ACEWM.