Pearls on Transitioning Patients Across Care Settings

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Hi, my name is Jeanine McGuire and I'm a physical therapist and certified wound specialist and also a PhD in health education and promotion. And my work has been around interprofessional wound management and how to really build teams for best outcomes.
 
What are the biggest challenges as the patient moves across the continuum of wound care?
 
Doesn't matter what setting you're in, there is a need for more wound education in every single setting from acute care to long-term care, home care and so on. And seldom are any of us prepared to practice at the level that we're expected to with regulations and to really meet the needs to prevent or mitigate litigation.
 
So the biggest challenge is really the lack of education and that's for providers, nurses, therapists, everybody on the entire team needs to have more education around wound management than what most of us receive in school.
 
How can providers best help patients navigate transitions in care?
 
The first thing that providers can do to help improve care is to seek advanced training in wound management to make sure that they're really practicing with evidence-based practices. And in fact, when I think about what I learned in school 30 years ago, it's very different than what we're doing today. So really recognizing that the evidence has really evolved and so our practice needs to as well. So physicians having or providers having some advanced training in wound management is key.
 
The second thing is really understanding product categories. So making sure that when there's a desire or a need for a particular product that there has to be that understanding of providers that across the continuum, everybody has a different formulary.
 
And so making sure that that patient will receive the right type of product is probably very important. So learning to write the orders under categories, you can certainly put brand name and parentheses, but allow for some deviation to make sure that that patient can get what they need in a timely fashion. And then I would say the third thing is to communicate openly to providers in other settings, but also to other team members and really understanding that they too may have very little knowledge. So really just having a collegial approach with each other so we can do better for our patients, our residents.
 
What do providers do right and what do they do wrong? 
 
One of the things that providers do really well in transitioning patients is providing some documentation of what services were done before that discharge.
 
Say at that physician that provider is in acute care, making sure that any relevant test or measures or blood work related to that wound were done in that setting before they go to home, home care, or any setting in post-acute care is really helpful to make sure that we can kind of take that and take it to the next level to provide them the right  treatments and interventions.
 
Another thing that providers do really well across transitions is have really vital communication with the family and with the patient around real goals of care. And so thinking about learning theory a little bit and really proceeding with curiosity, with that patient, with the family to try to understand what's their degree of wound literacy. Do they even know why that wound is there?  Do they understand what they may have to change in their behaviors to get to a point of healing if that's a possibility?
 
And if that's not a possibility, that provider is the lead in having those really critical and honest conversations about, okay, if this is the way that you're going to move or eat or the procedures that you're willing or not willing to do, then what is a realistic outcome? And how can we work with that patient, their family, to really maximize quality of life in the case when perhaps healing isn't their goal?
 
What are the biggest reimbursement challenges in transitioning patients?
 
That's a really good question because reimbursement, just like regulation, is different in every single setting. And so that's close to impossible for a provider, a therapist, a nurse, anybody to really understand those barriers across the continuum. And that's where a wound specialist can be very helpful if they understand the reimbursement structures, the regulatory structures. So here's a great example.
 
If I have a resident in skilled nursing and they're going to be discharged to home with home care services, I know that if they're receiving a treatment that requires that nurse  to come there daily, that's not feasible for home care.
 
So we really have to think about what that next setting can really do and what constraints they're under. So really understanding those regulatory challenges and reimbursement challenges or making sure you have a patient advocate who can help with that conversation is really important.
 
What is the Wound Provider Group Checklist?
 
One thing I'll add about providers getting involved with wound management. We need providers involved with wound management. So this is a huge gap where we really need the providers to step in and help lead that team.
 
But secondly, the providers must understand the regulatory issues, constraints, frameworks in the setting that they are working in. So for example, a provider coming to, say, long-term care must be aware of the regulations that impact that setting in this country and they have to have an understanding of how to work within that regulation so they can help us achieve success with survey and not be a cause of a survey tag. And certainly the provider does not want to be the cause of a survey tag. So work with the center, understand CMS guidelines, and again, this is where some advanced training can come into place.
 
So recently, there were a group of us, all different interprofessionals across post-acute care that recognize this vital need to make sure that the providers that are surveying us across the continuum really do meet all those expectations, but also for a provider that has intentions of working in that space, making sure they have sort of a template to use to also seek the right information.
 
So this group created what we call the Wound Provider Group Checklist, and the name of our group is PWSIC, so it's Post-Acute Wound and Skin Integrity Council. We have a board of 19 interprofessionals representing most settings in post-acute care, and one of our first deliverables was creating this checklist because it's certainly a pain point for us all across post-acute care, but we also want to have a collegial approach with our providers.
 
We want them to be as successful as we're going to be by having them on our team.