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More rehab departments embracing the concept
The old saying, "When one door closes, another opens," might apply to the use of wound management programs by rehabilitation departments. The same rehab departments that are stretched thin in terms of commercial and Medicare reimbursement are building revenue and improving patient outcomes through wound care and wound management.
Adding wound management services can generate between $200,000 to $457,000 in revenue annually for a hospital, depending on the size of the institution, says Pam Unger, PT, partner and clinical director of The Center for Advanced Wound Care in Wyomissing, PA.
"After our first eight months [of operation], we’ve been a money maker," she says. "This is an area that’s booming across the entire country. There’s still reimbursement for it. [Wound care] has been identified as something that exists and needs to be treated. [Rehab departments should] try to intervene with a service that’s revenue- generating but also produces a positive outcome."
Although not a new concept, the area is rapidly being embraced by therapists. More than 20% of physical therapists responding to a survey sponsored by the Alexandria, VA-based American Physical Therapy Association (APTA), the wound management special interest group, say wound care management should become a recognized specialty in the physical therapy field, says Carrie Sussman, PT, president of Sussman Physical Therapy Inc. and Wound Care Management Services in Torrance, CA.
"More than 1,100 respondents felt it should be a part of the practice of physical therapy. Eight hundred specifically said that it is part of their practice," says Sussman, a frequent consultant on wound management in physical therapy.
"Historically, therapists got into wound care via hydrotherapy, such as Hubbard tanks. But today, it has evolved to where therapists are doing open wound care. We’ve taken it to a more defined role," says Cordell Atkins, PT, a certified wound specialist who is a senior therapist and crew leader at Intermountain Health Care in Salt Lake City. Atkins also serves as chairman of APTA’s wound management special interest section. "But in our physical therapy role, we have to demonstrate a functional outcome. If we’re working with pressure ulcers, we may also have mobility activities or positioning activities. If I look at diabetic wounds, I may look at gait activities, pressure reduction, total contact casting, or [shoe] insoles or inserts."
The common denominator among hospital rehab programs that have implemented wound management techniques seems to be the presence of a therapist interested in this area. For example, Unger entered the wound management area in 1981 when working in a nursing home. "Every time I had a patient with a wound, the wound got in the way of rehab. A patient wouldn’t be able to do his exercises or ambulate because he had a wound in his heel, for example," she says.
After doing some research and attending continuing education courses on wound management, Unger decided to develop a PT-directed wound care center, operating first out of the hospital’s inpatient therapy department and eventually as a wound clinic within the hospital. Initially, she worked as a consultant three days a week, helping the department beef up its wound management program and dealing with patients who had specific wound management needs.
Growth occurred gradually
It didn’t take long to establish a patient base. Because the hospital rotated therapists among inpatient care, acute care, and other rehab settings, Unger developed a good referral base between staff therapists and hospital physicians. "I took orders that came down from the physician, assessed the patient, and called the physician to discuss a care plan. The only outlay [to the hospital] was the cost of using me as a consultant." Unger billed a consultant’s hourly fee to the hospital.
Eventually, Unger’s patient load grew large enough to justify establishing an on-site wound management department with ancillary clinical services at the hospital. "Initially, it was just me and a receptionist, and later we added a physical therapy assistant," she says. As patient volume increased over the years, The Center for Advanced Wound Care gradually grew to its current staff of nine. The center also added a satellite office with a staff of four.
"Don’t think you need to do it all on day one," advises Unger, who consults with hospital rehab units hoping to start a wound management program. "We have our best success with clinics when we start small and progress and grow."
Atkins’ involvement in wound management has led to the development of a physical therapy team specializing in wound management at Intermountain. Atkins and a partner, another physical therapist, work a seven days on/seven days off 10-hours-per-day schedule. The physical therapy team receives referrals from hospital and outpatient physicians — including plastic surgeons, general surgeons, orthopedists, endocrinologists, internists, family practitioners, and podiatrists — as well as hospital-based nurse practitioners and physician assistants. The physical therapy team is able to treat the patients in their rooms or in the hospital physical therapy department, depending on the patients’ needs.
Hospitals shouldn’t expect to see this kind of patient volume immediately, however. Atkins has been providing wound management services for more than 17 years.
At the Veterans Administration Medical Center (VAMC) in west Los Angeles, the rehab department has seen subtle changes rather than dramatic ones since it began offering wound management treatment two years ago, says Randi Woodrow, PT, manager of physical therapy at the hospital.
"We’re using staff time in a better way, and the costs have been minimal," she says, adding that the hospital has not totaled the costs of adding the program because funds were drawn from the department’s continuing education budget.
Sussman instituted a wound management program for a skilled nursing facility to treat patients with severe mobility impairments who had developed pressure ulcers. She found that the treatment improved patient recovery time and became an additional source of revenue for the facility. She since has branched out into a specialty in wound management consulting for physical therapists and has co-written a book titled Wound Care: A Colla borative Manual for Physical Therapists and Nurses.
VAMC’s decision to enhance its wound care program was driven by the physical therapy department, Woodrow says. "We had a physical therapist who came to us with wound care experience," she recalls. "We didn’t know what we were missing. She shared current information and education with us. It was really through her pushing that we identified that our knowledge wasn’t as current as it could be."
The hospital used Sussman to train some of the staff therapists as well as educate its attending physicians and residents, who primarily are physiatrists, Woodrow explains. After the presentation, the hospital’s staff therapists invested time in educating physicians one-on-one.
"It was really very time-consuming. Tradition ally, physicians would order a whirlpool treatment [for a patient with a wound infection] followed by betadine. Our message was that there are methods that are less invasive and more cost-effective" such as collagenase or hydrophilic dressings, she says. "It was a process. It wasn’t like we decided to do it one day and had approval the next. The entire process [of educating physicians] probably took a year."
Sussman agrees that physician buy-in is essential to starting a wound-management program. "Pitch it as another revenue-generating center," she suggests. "It’s almost like taking your car in to be repaired. Your first two questions to the mechanic are, When can I get my car back?’ and How much [will it cost]?’ Similarly, physicians want to know when [you plan to implement the program] and what are the expected results. And what research do you have to back it up?"
Woodrow says that although her department has not documented the cost and outcomes of wound management treatments vs. the whirlpool treatments typically recommended by the physicians, she has no doubt that the wound care techniques are saving time and money.
Physician support is just part of the multidisciplinary team effort needed for a successful wound management program, say Sussman and Unger. "I pretty much did it all on my own initially when I started this in 1981, but you just can’t do that [today]," Unger asserts. "You’re not with a patient 24 hours a day. You need nurses, dietitians, and specialists like podiatrists or plastic surgeons."
Program needs multidisciplinary approach
If you think of the traditional wound management program as changing dressings that contain high-tech medications, you’re missing the boat. Effective wound care involves collaboration among therapists and other staff clinicians, as well as frequent monitoring of patient outcomes, according to therapists with wound care experience.
If your rehab department is considering adding a wound care program, these pointers may help:
1. Wound management takes a multidisciplinary approach. "It’s very obvious that [therapists] don’t have all the answers," Sussman says. She recommends working very closely with nurses, who frequently are the referral sources for wound healing treatments by physical therapists. Both parties need to explain the treatment each is providing to the patient and the expected outcomes and should make certain they are compatible.
Unger says her center, The Center for Advanced Wound Care, was created with a team concept in mind. She serves as clinical director, and a physician serves as medical director. The center also includes a wound care department and a wound management department. The latter includes diabetic educators, vascular services, and podiatrists, who serve as consultants.
2. Approach the patient when developing outcomes. Patients should be a key part of the outcomes goal-setting process, Sussman says. "It’s not always as obvious as one might think. I once saw a patient who came in with a very heavily draining wound that had a lot of pus and odor. It was keeping her confined to home. What she wanted was to be able to control the odor so that she could get out of her house and go to church on Sundays and to see her family. That was her desired outcome."
3. Distinguish between wound care and wound management to receive proper reimbursement. "Wound care, including wound cleansing, administration of topical pharmaceuticals, and dressing changes, is typically considered a nursing service," Sussman says. "To distinguish the services of the nurse from those of a physical therapist, think of the physical therapist performing wound management, which incorporates the evaluation process of the physical therapist and the selection of interventions. It may also include the administration of these interventions or instruction, along with the wound care.
"In order to be considered a [reimbursable] PT service, it must include a service that is unique and that specifically requires the skills of a physical therapist. Examples might be: selecting electrical stimulation protocols, or sharp wound debridement accompanied by another service, such as whirlpool or pulsatile lavage with suction. Also, rehab may be a part of the wound service, such as treatment of an amputee who is undergoing gait rehabilitation," she says.
4. Develop a protocol for your wound care program. For a sample pathway:
• Include wound assessment as part of the initial evaluation done by the physical therapist.
• Determine if any interventions are needed to heal a wound or prevent a future wound from developing.
• Determine the type of intervention needed.
• Communicate the information to the attending physician or other appropriate parties.
• Determine who does what tasks. For example, who changes the dressing? It isn’t always the nurse. "Therapists are qualified to put on a dressing and topical agents, if they’re doing it in the course of providing therapy," Sussman says.
At VAMC in west Los Angeles, the protocol involves team rounds of all patients who are at risk for wound problems, says Woodrow. If team members see a patient at risk for developing wound problems, they will add recommendations to the patient’s chart, whether it involves a dressing change or a treatment in the physical therapy gym.
At The Center for Advanced Wound Care, patients are classified into a specific category based on the type of treatment needed, following an initial 2.5-hour visit that includes an assessment by a physical therapist and a physician and patient history data provided by a registered nurse. Patients are classified as post-surgical, traumatic, or burn patients.
The center also might use basic admitting and treatment protocols that go with each category, at least as a starting point. "The physical therapist writes a plan of care [based on these protocols] with input from team members," Unger says.
"Based on the type of case, it might include ultrasound, pulse electromagnetic induction, dressing changes, total contact casting, and exercise programs from the therapist’s perspective. It also might include antibiotics or nutritional education. But the plan of care may change as things happen with the patient," she says. Once a week, the clinic has all professionals involved in the care — from surgeons to nurses to other providers — meet to review the patient’s progress.
5. Don’t forget about prevention. Spinal cord injury patients and stroke patients are among those who frequently are at risk for wound problems, Sussman says. Prevention planning could be part of an initial evaluation as well as ongoing patient assessments.
6. Remember: There is strength in numbers. The APTA has a wound management special interest group that is part of its section on clinical electrophysiology. Contact the association at (703) 684-2782 or on the World Wide Web at www.apta.org.
APTA files class action suit
In addition to acting as a resource, the group has gotten involved in reimbursement issues affecting wound management in rehab settings. For example, APTA filed a class action suit against the Health Care Financing Administration protesting HCFA’s refusal to cover electrical stimulation by therapists for wound management purposes. The suit led to a court ruling that required HCFA to consider reimbursement for these services on a case-by-case basis.
7. Research costs and desired outcomes when beginning a program. Potential sources include the National Pressure Ulcer Advisory Panel, which holds regular conferences and is planning a conference for Oct. 6 in New York City. Contact the organization at (314) 909-6815. Sussman’s book, Wound Care: A Collaborative Manual for PTs and Nurses, written with Barbara Bates Jensen, RN, is available from Aspen Publishing Co. for $85.