My Scope of Practice: Managing Costs and Wound Care in Brazil

Obviously, the highest type of efficiency is that which can utilize existing material to the best advantage. —Jawaharlal Nehru, first Prime Minister of India

Quality health care for patients involves providing evidence-based treatment and the tools necessary to effect that treatment. But one thing often is overlooked: costs. In Rio de Janeiro, Brazil, Ana Clara de Melo Souza Tolentino, RN, WOCN, MSc, MBA, NP strives to offer the most affordable health care available to her patients. “Although we work in a socialized health care system, the reality is most of the covered hospitals do not have access to the newest technologies in the area,” Ana Clara says. “The challenge of working with scarce resources is draining. Regardless of the economic status of the patient, finding an affordable wound care treatment is not that easy. To overcome these obstacles, I use my knowledge of wound and ostomy care, the evidence in the literature, and economic factors that take the patient’s budget into consideration.”

“I have personally experienced how physically painful it can be to have a burn treated, which I believe naturally compelled me to help others who are in physical pain,” Ana Clara says. “When we covered wound and ostomy care in nursing school, I realized this was my professional passion.” 

While Ana Clara worked toward earning her nursing degree in 2004, she began volunteering in a Catholic Franciscan Center in Rio de Janeiro that provided health care assistance to homeless people. “Most of these patients had chronic wounds, so once or twice a week I brought donations from my family and friends and samples from the conventions and symposia I attended, which included products from sterile gauze to costly dressings,” she says. “I also taught the Franciscans how to change the dressings, how to clean the wounds, and the like. I knew providers have to be concerned about the financial as well as clinical aspects of care, so not only did I earn my RN license in 2008 from the Federal University of Rio de Janeiro, but I also earned my MBA in 2010 from the Brazilian Institute of Capital Markets and my MSc in the health economics field in 2013 from the Federal University of the State of Rio de Janeiro (UNIRIO). I also attained my Brazilian wound, ostomy, continence (WOCN) certification in 2013 from the University Gama Filho.” Currently, Ana Clara is pursuing her PhD in Health Economics while working at the Federal University. She also is a professor at Rio de Janeiro State University and University Estácio de Sá.

To enhance her learning, Ana Clara attends conferences such as the Symposium on Advanced Wound Care, presenting posters on relevant topics such as “Cost-effectiveness analysis of one-piece drainable pouch versus the two-piece system for colostomates: the perspective of patient’s out-of-pocket expenses in Brazil.” She also provides consulting services in health economics and wound care through her company, Tissular – Enfermagem Dermatológica, and she works as an RN in acute care at a university hospital. She is also a member of the scientific board of the International Society for Pharmacoeconomics and Outcomes Research and an editorial advisory board member of Ostomy Wound Management.

Wherever she works in the health care field, available resources remain a primary concern. “A public hospital in Rio de Janeiro is a complex environment, full of obstacles and difficulties,” she says. “My job is to overcome them. Often we face a lack of basic materials such as barrier cream, ostomy pouches, or gauze.” In these situations, Ana Clara first conducts a physical exam and medical history of the patient and then she looks into the available options that specific patient has available to him or her based on the cost, duration of treatment, and types of treatment. “For example, a patient needed to control wound exudate and needed a nonadherent dressing,” she says. “But this patient could not afford to buy an absorbent foam, and the hospital didn’t have any available. I taught the patient how to use the nonadherent gauze to protect the wound from adhesion and to use normal sterile gauze as a cover dressing to absorb the exudate. It’s simple but effective. As a volunteer in an extremely poor community, I learned patients were washing their bandages to reuse them on wounds. That touched my heart.”

Ana Clara’s responsibilities, studies, and work ethic are vital not only to health care in Brazil, but also to health care on a global scale. “Although I am an independent health care professional, I have been in charge of evaluating the options of the most cost-effective solutions in wound and ostomy care private health care companies (especially those in home care settings) can provide and creating health economic models for third parties in order to analyze global markets,” she says.

While Ana Clara maintains busy work and personal lives, she tries to relieve stress by spending time at the beach or with her family. “I cannot separate my life from my work,” she says. “I intend to earn my WOCN certification in the United States and to become a resource in wound care and health economics in Brazil, similar to a role model of mine, Professor Laura L. Bolton. To do so, I plan to finish my PhD and to dedicate myself to growing my consulting activities in health economics and teaching at the university.”

Recognizing the team-oriented spirit of nursing is a valuable lesson Ana Clara has come to preach and practice in her work. “No one can work alone, especially in health care,” she says. “Working as a team can save you a lot of energy that could be better spent on a more important task. By working in a team, we also have the opportunity to learn more and provide more comprehensive care for our patients.” Juggling a patient’s physical care and comfort, financial needs, and the products and services available isn’t easy, but it’s all part of Ana Clara’s scope of practice.

This article was not subject to the Ostomy Wound Management peer-review process.