Continence Coach: Our Moral Obligation to Skin Care: Calling for Inclusivity

Absorbent Quality Performance Standards

  A council headed by the National Association For Continence (NAFC) recently released its recommended national quality performance standards for disposable adult absorbent products for incontinence in frail, elderly, and/or disabled populations.¹ The council focused on products provided and paid for by states to Medicaid waiver recipients cared for in their private homes, but the recommendations are considered applicable to consumer purchases of retail product as well as product purchased for use by hospitals, nursing homes, hospice centers, and similar facilities. The complete draft recommendations can be found on the NAFC’s website. The recommendations were publicly vetted for commentary for a 60-day period ending in early September. Final recommendations are anticipated before year’s end 2012.   The recommendations cover eight specific product characteristics/measures:
    1. Rewet: a product’s ability to withstand multiple incontinent episodes
    2. Rate of acquisition (ROA): the speed at which urine is drawn away from the skin
    3. Retention capacity: a product’s capacity to hold fluid without releasing it
    4. Sizing options: availability of a selection of youth and adult sizes to optimize fit and performance and to reduce waste
    5. Safety: assurance of safety; none of the components in an absorbent product should be considered unsafe by any federal regulatory agency
    6. Presence of a closure system: incorporation of a mechanical closure system to allow for multiple unfastening and refastening in order to prevent waste
    7. Breathable zones: an acceptable minimum air flow in side “wings” of the product, sufficient to release trapped body heat/gaseous body perspiration in these areas
    8. Ability to contain fecal matter/loose stool; evidence of the product’s ability to deliver a gentle, snug fit using leg and waistband elastics.

  Council members include individuals responsible for managing the Medicaid waiver programs for their respective states in various regions of the country, specifically California, Massachusetts, Minnesota, South Carolina, and Texas, as well as technical directors from leading US manufacturers of nonwoven products. Other Council members include representatives from the Nonwovens Industry Association (INDA), the National Family Caregivers Association (NFCA), and the Wound Ostomy Continence Nurses (WOCN) Society. The council, formed as an NAFC initiative,² has been meeting monthly and developing the recommendations for the past 18 months.

Catalyst for the Initiative: Medicaid Waivers

  The acquisition of supplies for managing incontinence among Medicaid waiver participants (and in some states, all Medicaid recipients) is being targeted to help curb expenses for many states whose spending budgets are increasing at higher-than-expected rates. Waivers originally were enacted as a means of saving the expense of costly nursing home or other institutional residence placement. However, some states have no quality standards to specify what types of supplies for incontinence are allowable, and most have relied simply on the lowest per unit price as the chief purchasing criteria. Some states have covered the cost of any product selected by a recipient’s family member but have no way to determine suitability for the user’s medical and physical circumstances. Few, if any, states have recognized evidence-based quality standards in their coverage and purchasing decision policies. Some products are sourced from manufacturers whose quality control is questionable and whose manufacturing process is subject to wide variation. Family caregivers are not necessarily educated about skin care, much less absorbent product selection. They may be lacking basic health literacy. Most states lack the staff and resources to help educate and guide family members about purchases, much less advise in matters of routine skin care and pressure ulcer prevention. As a result, there are anecdotal reports of resulting skin health problems. Although the prevalence of these problems remains undocumented, one can speculate about the multiple causal factors involved in any such events.

Incentive for Coordination and Coverage versus Constitutionality and Contention

  Such recommendations are just the beginning of progress in bringing improvements in healthcare — primarily because of the spirit in which they were developed. Providers, health plans, governments and municipalities, employers, and consumers all are looking for innovative approaches to address challenges associated with quality, efficiency, care delivery and coordination, and cost-effectiveness. The Patient Protection and Affordable Care Act (PPACA)³ included potential solutions, such as accountable care organizations (ACOs), designed to realign incentives within the delivery system to better meet these challenges and improve outcomes.

  Yet, following the Supreme Court’s recent decision⁴ that Congress does not have the authority to withhold funding for states’ existing Medicaid programs if they fail to expand Medicaid to low-income adults, many questions remain regarding implementation of the remaining PPACA provisions relating to Medicaid expansion. It is unclear whether the Department of Health and Human Services can grant states permission to partially expand Medicaid for low-income adults to an income level below the 133% of Federal Poverty Level (FPL) previously required and still grant the full funding for the expansion included in the law. Already, at least six states have indicated they do not plan to expand Medicaid, with another six leaning in the same direction. Low-income adults between 100% and 133% of FPL are eligible for subsidies under the proposed health insurance exchanges, so a state’s failure to expand will primarily affect uninsured adults earning <100% FPL.

  Following the Supreme Court’s announcement upholding the constitutionality of the individual mandate, governors of several other states defiantly announced they would not be implementing exchanges. These states include: Alaska, Florida, New Hampshire, South Carolina, and Texas. (Florida is implementing its own version of an exchange that does not meet requirements defined in the PPACA.) Where does such dissention leave clinicians?

Finding Pathways for Inclusivity

  Economic and social circumstances today call for collaboration, consensus, cooperation, and creativity — not conflict —in finding novel ways to restructure healthcare delivery. We need to think in terms of inclusivity rather than exclusivity in order to help the greatest number of people, especially persons with the gravest needs. The NAFC’s recommendations for establishing quality performance standards for absorbents are aimed at elevating the value of product used to help safeguard fragile and vulnerable skin from dermatitis, skin erosion, and skin breakdown.⁵ Isn’t every patient morally deserving of such care and protection?

Dr. Muller is the Executive Director, National Association For Continence (NAFC). The NAFC is a national, private, nonprofit organization dedicated to improving the quality of life of people with incontinence. The NAFC’s purpose is to be the leading source for public education and advocacy about the causes, prevention, diagnosis, treatments, and management alternatives for incontinence. This article was not subject to the Ostomy Wound Management peer-review process.

1. National Association For Continence. National Quality Performance Standards for Disposable Adult Absorbent Products for Incontinence in the Frail, Elderly and/or Disabled Populations, July 1, 2012. Available at: www.nafc.org/find-a-product/absorbent-products/. Accessed August 8, 2012.

2. Muller N. Continence Coach: Lean manufacturing for patient-centered continence care. Ostomy Wound Manage. 2011;57(1):18.

3. Patient Protection and Affordable Care Act. March 23, 2010. Available at: www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf. Accessed August 8, 2012.

4. Supreme Court of the United States. Department of Health and Human Services versus The State of Florida et al. June 28, 2012. Available at: www.supremecourt.gov/opinions/11pdf/11-393c3a2.pdf. Accessed August 8, 2012.

5. Shigeta Y, Nakagami G, Sanada H, Konya C, Sugama J. Factors influencing intact skin in women with incontinence using absorbent products: results of a cross-sectional, comparative study. Ostomy Wound Manage. 2010;56(12):26–33.