Strive to keep LOS under 60 days
A hospital-based Kansas home care agency discovered an interesting trend among its wound care patients after tracking their progress and outcomes in the past year. Most of the patients either were successfully treated within 60 days or their wounds took more than 150 days to heal.
"That tells you that I can either get you healed within one Medicare period of 60 days or you’re going to be with us for a long time," says Martha McCabe, administrator of the home health department of Susan B. Allen Memorial Hospital in El Dorado, KS.
That piece of information, which the agency learned through consistent data collection on wound care patients, helped McCabe and other managers decide where to focus.
The information also confirmed the agency’s success in treating wounds. Of the 48 new wound cases the agency began in 1998, 32 cases were discharged by the end of the year because the wounds had healed. Another six were discharged before the wounds had healed because the patients desired to be discharged or the patients were no longer homebound. The remaining 10 cases that continued to receive wound care treatment in 1999 involved people who had a chronic wound history because of diabetes, multiple sclerosis, or other illnesses. Still, in nine of these cases, the patients were healed and discharged by June 1, 1999, McCabe says.
"The one we have remaining is a multiple sclerosis, bedbound patient who has recurring skin breakdown," she adds.
Develop new protocols
The wound care data have reinforced how important it is for the agency to aggressively promote faster healing and lower the patient’s length of stay through the use of new technology, more persistent patient/caregiver teaching, and better staff training, McCabe explains.
"Our philosophy and goals remain that if a patient needs a service and the doctor orders the service, we’ll continue to provide the service regardless of the cuts in reimbursement," she adds. "But we’re more aggressive and we’ll use products that have quicker outcomes; and if there are caregivers in the home, we’ll try to teach them how to do a clean dressing change."
Here are brief descriptions of some of the changes the agency has made to improve its wound care patients’ outcomes and to lower their length of stay:
• Develop new protocols. All registered nurses and managers met at an annual planning meeting to brainstorm about ways to improve the agency. "We have big boards where we list all the great things we did this year and all the things we need to improve," McCabe says.
While there, the staff decided to focus on wound care and develop new wound care protocols.
Later, McCabe revised the protocols and presented them for suggestions and approval at a staff meeting. The staff looked at the new protocols and then discussed, debated, and revised them. The final product had to be approved by the entire staff. (See new wound care protocols, p. 109.)
• Educate nurses and aides about wound care. The agency sent all nurses and a physical therapist to three days of intensive wound care workshops in 1998.
Also, the agency holds a wound care inservice each year for the entire staff. Typically this gives the staff an update about new wound care treatment and is a free service provided by a pharmaceutical company representative.
Plan weekly meetings
Since the agency’s new protocols call for aides to make more clean dressing changes than they had been expected to do before, the agency also started holding inservices for home health aides on wound care. The aide inservices included information on clean dressing changes, how to recognize infections, and basic infection control.
• Improve team communication. At the annual planning meeting, the staff decided that better team communication was necessary. The agency added two 15-minute meetings to the weekly schedule. One is 8 a.m. on Mondays to discuss what happened with patients over the weekend, and the second is 8 a.m. on Fridays to discuss what patients are being admitted and discharged over the weekend.
"They meet in my office and discuss new patients and patients who are being discharged, and this helps the nurses who are on-call for that weekend," McCabe explains. "We have found that communication with those two little short meetings has saved more confusion than ever before."
The agency also holds team meetings on wound care patients at a minimum of every two weeks, although these sometimes can be held once a week. The team reviews the patient’s progress in healing and discusses any treatment changes that might be necessary.
• Use new medicines and treatments. Patients are treated with collagen-alginates. And some physicians have begun to order Regranex, which is a topical cream treatment for leg and foot ulcers. It works well for diabetics, McCabe says.
Nurses document wound care patients’ progress, even using photographs to show before, during, and after pictures. When a wound appears to be healing too slowly with one medication, they will call the patient’s physician and recommend a change.
"We use different products, and if something is not working, we’ll make a change," McCabe says.
The agency also has had some bedbound patients try some of the newer types of mattresses to reduce skin breakdown.
• Improve patient/caregiver education. Caregiver and patient education continues to be a major area of focus in wound care, McCabe notes.
"Probably the best thing we’ve done for wound care patients is to be more aggressive with them in teaching them how to deal with their condition," she explains.
Nurses teach patients upon admission about the homebound rules governing Medicare home care patients. "We’re even more up front than we used to be," McCabe says. "We put an explanation in the admission packet about homebound status, and we tell them, If you drive just once, we’ll discharge you. If you go out of your house more than once or twice a week, you’re discharged.’"
Nurses further explain that to receive home care services, a patient has to have an inability to leave his or her home.
They also tell patients that the agency’s goal is to help patients become independent again, and preferably to help them recover and begin moving around and enjoying life within four to six weeks, depending on their health problems.
Basic patient wound care education also includes information about infection control and handwashing. Although that may seem basic information, McCabe says, nurses have often discovered that patients don’t understand how important it is to prevent infections by washing their hands. The introductory packet also includes educational material about handwashing.
"We go over that with wound care patients on every visit," she states.
Finally, whenever possible, nurses teach caregivers how to care for a patient’s wound. Previously, nurses would change all dressings, but under the prospective payment system, this is too costly a policy to continue.
"If there are caregivers in the home, we try to teach a willing caregiver how to do a clean dressing change," she says. "If it’s a sterile dressing change, then the nurse still has to go in daily to do that."
For example, the agency recently had two patients whose wounds stemmed from recent surgeries. Both patients had caregivers who were willing to be taught how to change their dressings.
On the nurse’s first visit, she taught them how to change the dressings. She also taught them the signs and symptoms of infection, handwashing for infection control, and how to contact the nurse in case of an emergency.
Then, the nurse continued to see the patients twice a week, monitoring the surgical sites, infection risk, and making sure the caregivers were properly making the dressing changes. Because of the caregivers’ assistance, the agency’s cost in caring for these patients is much less expensive, and the patients probably will be discharged within four weeks, McCabe says.
"We’re trying to empower people to take charge of their situation, and we’re very clear with our patients that home care is a part-time, intermittent program," she adds.
• Allocate staff time more prudently. When a patient has no willing caregiver to assist with dressing changes, the agency will provide the service. However, the agency decided last year that it was too costly to continue having registered nurses provide simple dressing changes, so aides now provide the service.
"The RN makes weekly visits to document, assess the wound, and make sure the standard of care is being carried out," McCabe says. "But we’ve found that a lot of the wounds have gotten to the point where they’re using a clean dressing or gauze dressing, and the aide can do this at a much lower cost than the RN."
The agency also made it a standard practice to automatically make a dietary referral when a patient has an open wound. This helps to improve outcomes and expedite healing since elderly wound care patients often have not been receiving adequate nutrition for healing.