How to Bring Value to Home Health Agencies for Patients With Bowel and Bladder Diversions

United Ostomy Associations of America (UOAA) is the nation’s leading organization advocating for quality care for people facing life-saving ostomy surgery and those who currently live with an ostomy or continent diversion. It is estimated that there are between 725 000 to 1 million people living with an ostomy and continent diversion, and approximately 100 000 surgeries are performed annually.¹ For the past 3 years, UOAA has focused on collecting stories of patients who have endured poor and inadequate ostomy care after discharge from the hospital. UOAA defines poor and inadequate care as care that does not meet the patient’s needs physically or emotionally and that does not provide a means for finding assistance after surgery and/or throughout the lifespan. 

The services of a certified wound, ostomy, and continence (WOC) nurse, or at least an ostomy-trained nurse, in home health agencies are limited. In many situations ostomates have poor outcomes due to improper care from untrained individuals. This is frustrating to our community when we know for Medicare beneficiaries, under §484.60, “Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence and that each patient must receive an individualized written plan of care that must specify the care and services necessary to meet the patient-specific needs.”² We are also aware that historically, many home health agencies have not accepted an ostomy patient referral, which then diminishes patient-preferred choice of care, which also by federal law is a guaranteed right for those on Medicare. 

In 2001, the Institute of Medicine made the recommendation for patient-centered care.³ In January 2020, the patient-driven groupings model (PDGM), which is the Centers for Medicare & Medicaid Services’ (CMS) overhaul of the home health payment system, became effective. According to the CMS, the motivation for the development of PDGM was that home health payment should not be based on the number of visits, but rather determined by focusing on the patient’s condition and putting the unique care needs of the patient first. CMS Administrator Seema Verma stated that it will allow home health agencies to leverage innovation and drive better results for patients.⁴ Could this be the long-awaited game-changer for patients with an osotomy while under home health care?

UOAA is encouraging home health nurses to work with their agencies that have not considered this underserved population. This is an opportune time to bring value to their agency by establishing a 5-star program of distinction for treating people with fecal or urinary diversions. Under the new PDGM 12 clinical grouping categories,⁵ complex nursing interventions (eg, assessment, treatment, and evaluation of complex medical and surgical conditions including intravenous lines, total parenteral nutrition, enteral nutrition, ventilators, and ostomies) place patients with ostomies in one of the highest potential reimbursement tiers, whether it is a new patient after surgery or an established ostomate receiving care in the home for a new medical condition. For example, a patient who has had an ostomy for 15 years and then had a stroke would receive their ostomy supplies under the prospective payment system and would also require reevaluation of their ostomy needs.

Preliminary data results of a UOAA study show that the greatest problem that patients with ostomies experience after surgery is pouch leakage. Industry and other studies^6,7 have validated these findings. As a result, many patients experience peristomal skin complications that can lead to hospital readmission due to skin infection. There are also accounts of patients seeking assistance in emergency departments due to having no ostomy supplies and using a plastic shopping bag adhered to their body with duct tape. Proper education on changing an ostomy pouching application system and ensuring the patient has access to and is utilizing the right products to meet their unique needs is paramount while under home health care. This can be achieved by adding the certified WOC specialty to home health services to improve patient outcomes. WOC nursing is one of the few specialties recognized by the American Nurses Association. This specialty has the added benefit of expertise in wound care. A WOC nurse can also let the medical staff know when it is appropriate to code the ostomy as complicated, which gives the agency the reimbursement it needs to properly take care of the patient while still being profitable.

Key components of a 5-star ostomy program to improve patient outcomes include the following:

• Evidence-based discharge criteria for the patient with an ostomy⁸

• Access to a board-certified ostomy nurse

• Evidence-based peristomal skin complication assessment and treatments

• Ongoing in-services and evaluation of staff competencies in ostomy care

• Access to the patient’s appropriate supplies to have 2 to 5 days of comfortable, predictable, and leak-proof wear time to avoid hospital readmission.

UOAA also offers the following resources for home health nurses and agencies to help attain a 5-star ostomy program as they implement PDGM:

• Utilize the UOAA checklist of evidence-based discharge criteria (Figure 1) to ensure positive outcomes based on a Wound, Ostomy, and Continence Nurses (WOCN) Society consensus panel. For example, 1 criterion is that the patient and/or caregiver is able to provide a return demonstration of how to change the pouching system including removal, cleansing, and application.

• Share resources with clinical staff, such as important reminders produced by the Access and Care Coalition,⁹ for treating patients with fecal or urinary ostomies and for people who use urologic supplies.

• “Reach for the Stars for Your Ostomy Patient” by utilizing these UOAA guidelines for home health agencies to deliver quality ostomy care (Figure 2).

As the home health care industry transitions from volume to value, this is a golden opportunity to improve ostomy care. Rather than neglecting patients with an ostomy, agencies should leverage their distinction for referrals by enhancing their repertoire of services and adding a 5-star ostomy program.

According to WOCN Society Public Policy and Advocacy Chair Kate Lawrence, MSN, RN, CWOCN, “Patient needs, combined with the ability of an agency to deliver the best clinical outcomes to meet those needs on a cost-effective basis will emerge as the driver of market success.”

For more helpful, free resources for home health providers caring for patients who have ostomies, visit www.ostomy.org and www.wocn.org. 

Disclaimer: UOAA does not endorse particular products, manufacturers, DME providers, or other sellers of ostomy products.  This column was not subject to the Wound Management & Prevention peer-review process.