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Wound care program keeps patients safe, out of hospital
Health plan collaborates with vascular surgeons, home health nurses
A team-oriented approach to working with members with non-healing wounds has paid off for UPMC Health Plan and its network providers.
In April 2010, the last period for which data are available, almost 89% of non-healing wounds achieved optimal healing response within eight weeks, says Roseann DeGrazia, RN, BSN, MEd, senior director, medical management for the Pittsburgh-based health plan.
The UPMC Wound Care Program is a collaborative effort between UPMC Health Plan, University of Pittsburgh Physicians Division of Vascular Surgery, the UPMC Center for Quality Improvement and Innovation, UPMC/Jefferson Regional Home Health LP, and the UPMC Wound Healing/Limb Preservation clinic.
The project's goal is to increase the healing rate of wounds and increase quality of life for members with non-healing wounds, DeGrazia says.
"As a health plan, we work collaboratively with our network providers on ways to improve care for our members. One of the areas we're interested in is wound healing. We decided to work with our vascular surgeons and the home care agency to manage members with chronic, non-healing wounds," she adds.
Members who have non-healing wounds with a duration of four weeks or longer are eligible for the program.
The program is designed to facilitate state-of-the art treatment for chronic wounds in the home care setting. Wound care specialists and UPMC Health Plan wound care case managers collaborate with the member's primary care physician on a treatment plan for the patient's wound. UPMC vascular surgeons review the wound information and treatment plan and offer suggestions to the treating physician.
"The goal of the program is to increase the healing rate by 50% in four weeks. If patients are on a healing trajectory after four weeks, the results will show. If not, the physician can change the treatment plan," DeGrazia says.
The health plan identifies many members for the program when they are hospitalized with non-healing wounds as a primary and secondary diagnosis. Other referrals come from physicians, home health agency nurses who are treating a different condition, and UPMC's case managers who may be working with members for a different reason and learn that they have a non-healing wound.
When a patient is referred to the program, Lori Painter, RN, BSN, CCM, wound care case manager for UPMC health plan, accesses the patient record and compiles a thorough medical history including medications and any co-morbidities.
The health plan has an integrated system, which allows the case manager to access utilization management information in the hospital, clinical data from claims, laboratory data and lab results, and pharmacy data, including what drugs were prescribed and when the patient filled them. Painter can leverage the information to help engage patients, DeGrazia says.
More than 40% of patients in the program have diabetes. Others have peripheral vascular disease or other conditions that compromise their blood circulation.
Painter calls patients referred to the program, finds out if they are interested in enrolling in the program, and if so, arranges for a specially trained wound, ostomy, continence nurse (WOCN) to visit the patient in his or her home.
"I do a thorough history of their social system. I find out if they have significant others or friends in the community to help care for them and if they live in an area where they have difficulties getting to their physician office," she says.
The program is optional for patients. If they opt out when Painter calls, she gives them information and the program phone number. If the patient ends up back in the hospital for wound treatment, then Painter initiates another outreach call.
"If the primary care physician recommends the program to patients, they're more likely to participate. We work closely with the primary care providers to keep them informed about the program, publishing information in our provider newsletter and attending their meetings," DeGrazia adds.
The patients have the option of having a home care visit, talking to the nurse, and then opting out of the program, but most choose to stay in the program, DeGrazia adds.
"We take a high-touch approach to wound care. Our patients are very satisfied with the program," she says.
Specially trained enterostomal nurses employed by the home care agency assess the patient in the home, then visit every two weeks, or more often, depending on the wound.
The nurse takes measurements and photographs of the wound and performs a Doppler study on the first visit to determine if vascular problems may be interfering with the healing. If so, she contacts the patient's primary care provider for a referral to a vascular surgeon in order to facilitate early intervention.
The nurse uses a special wound care photo information form to record the type of wound, the height and depth, type of drainage, and the treatment protocol, DeGrazia says.
The wound care nurse sends photographs and measurements of the wounds every few weeks to Painter, the primary care physician, and the vascular surgeons group, which oversees the program, DeGrazia says.
The UPMC vascular surgeons review the wound photo information form in order to assess the progression of healing and offer recommendations for change to the wound care protocol as needed, she says.
The primary care physician is responsible for the management of the patient and takes into consideration the input from the wound care photo information form, the home care WOCN nurse, and the wound care reviewing vascular surgeon. Changes to the wound care treatment protocol are made only as ordered by the primary care physician, she says.
If the wound doesn't improve within a certain time, the reviewing vascular surgeon may recommend a change to the wound care treatment as per the protocol, DeGrazia says.
Painter is involved in transitioning patients from the hospital to home, enrolling the patients in the program, and letting them know when the home care visit is scheduled.
She collaborates with the WOCN nurse to make sure the patient understands everything he or she needs to know for self-care, such as how and when the dressing should be changed and what medication should be applied in between visits from the nurse, she says.
She makes sure the patients understand their condition and their discharge instructions and answers any questions they may have. In some cases, she may need to clarify the treatment plan with the physician, she says.
She communicates with the home care agency nurse by telephone and by e-mail and calls patients frequently, usually weekly or bi-weekly depending on the patient's preferences and condition.
When she calls patients, Painter conducts a medication review, making sure the patients got their prescriptions filled, going over the medications and when and why they should be taken, and helping patients understand why they may need to take multiple drugs, she adds.
If the patient is a diabetic, she educates them on the disease process and enrolls them in the health plan's diabetes program.
"I educate them on the importance of checking their blood sugar and taking their medication as directed. I explain that elevated blood sugar can cause healing to slow down and make sure they are getting enough protein in their diet to help with healing. If they are having trouble controlling their blood sugar, I contact the primary care provider to discuss treatment, including the need for further evaluation by a diabetes specialist," she says.
"The wound care case manager is the key contact for the patient while the patient is in the program. When the wound heals, she transitions the patient to a disease management health coach for ongoing support in keeping his or her diabetes under control," DeGrazia says.
Managing the care of the patients is a team effort, Painter points out.
"If I find patients are having difficulty getting in to see the doctor or have problems paying for their treatment, I can get the health plan's social worker involved. The pharmacist who is embedded in the care management department is available to conduct a medication review or assist with pain management," she says.
One patient wasn't going for follow-up visits because she couldn't afford her copay. Painter alerted the social worker who helped the woman sign up for charity care to help with the copays.
If the patient is having trouble with general medical care, Painter can call on the health plan's mobile case manager to go into the home and assess the situation.
"I have a network of people I can call on to enhance the quality of life for these patients. We work as a team to look for ways to avoid repeat admissions and complications including pain management issues," she says.
She conducts a depression screen on all the patients and refers appropriate patients who agree to the health plan's behavioral health program.
For instance, one patient who was facing an amputation told Painter he was afraid and didn't think he could handle losing his limb. She called in the home care behavioral health nurses who visited him in the home and helped him learn to cope with the changes to his daily life.
The wound care team takes a holistic approach to treatment, Painter says.
"At UPMC, our job is not just to take care of the wound. We try to involve the patient, the whole family or caregiver, and the community in helping people maintain their health," Painter says.
For instance, when Painter called one patient to remind him of his appointment with a vascular surgeon, the man told her he couldn't go because he was out of colostomy supplies. Painter called the home health agency, which put out a bulletin to the nurses serving the patient's area, and one of them brought extra colostomy supplies to the patient's home.
The wound care nurses and Painter meet at least quarterly and discuss the individual members enrolled in the wound care program wounds. The team addresses any barriers to healing. The team meets regularly with the vascular surgeons to go over the patient records and treatment plans.
"As a payer, we have a lot of information that can be useful to the integrated care team. We know the utilization data, including claims, and pharmacy data. In addition, our case managers and social workers know the psychosocial history of these patients and can collaborate on the plan of care during case conferences," DeGrazia adds.
Members of the wound care team get to know each other very well and are very familiar with the patients, their wounds, their treatment plans, and their progress, DeGrazia says.
The team reviews the wound care protocols annually to determine if there are new products or new treatments that may benefit the patients, she says.
Patients are discharged from the program when their wound is healed. The case manager gives discharged patients a number to call in case they have any problems.
Before starting the program, DeGrazia, Painter, network managers, a representative from the home care agency, and one of the vascular surgeons met with provider groups who have the highest volume of UPMC Health Plan members, educated them about the program, and asked them to refer their patients who have non-healing wounds to the program, DeGrazia says.
They also met with the vice president of nursing, director of case management, wound care teams, and the utilization management department at hospitals in the network and shared information about the wound care program.
After successful pilots with the wound care program, UMPC Health Plan and Home Health shared their expertise with other health plan network home care agencies.
"We have contracted with our home care agency, UPMC/Jefferson Regional Home Health LP to conduct training for participating network home care agencies interested in the wound care program," DeGrazia says.