Transcript
Speaker: in our outpatient space, we so often miss what is actually going on. Like the patient's going to come in. And I think Jen and Annie, I think we've had patients that we share with this where like, and you'll be texting me like, Karen, like you realize this guy is like, you know, urine saturated dressings or walking on his foot all day. And the patient comes in into me and they're like, Karen, I don't walk at all.
Speaker: have my own fling boot on all the time. i never eat cookies. Right. And then Annie's like, wait a minute. Yeah. He has a bag of cookies and by his bedside. Sure. Yep. It's bad cup, good cup. Hello everyone. Welcome to Healing by Design.
Speaker: the podcast where we amplify the voices that matter most in wound care. I'm Jen Bierup and I am here with my co-host, Therese Laub. We are so glad you found us and we can't wait to dig into today's conversation.
Speaker: Before we jump in, I do wanna take just a quick moment to cover a few things. Everything we talk about on this podcast is meant to educate and inform. It's not medical advice and it shouldn't be taken as a diagnosis or treatment recommendations. Your situation is unique and your healthcare care provider is always your best resource for decisions about your care.
Speaker: The opinions our guests share are their own. They don't speak for POSIC or our sponsors. And if any of our guests have professional or financial ties to products or companies we discuss, we'll always be upfront about that. One more thing, if you're ever dealing with a wound care emergency, please don't look to us for that. Go to a provider right away. Now that we have all of the disclaimers out of the way, let's dive right into our show.
Speaker: Each of you guys are here because the main point of this is for us to represent our own spaces and discuss what we you know what we need to do to work together better, break down those silos, transition our patients better. um How we're going to kind of work this, and i'm gonna let Therese take over in just a second, is this going to be a little weirder because I am going to kind of represent the acute space.
Speaker: So I'm going to be your friendly, happy, acute space person. Please be nice to me. Okay. And Therese is really going to take the lead on um really kind of um breaking it out and discussing. If you guys have a burning like, oh my gosh, I have to make a comment, like raise your hand.
Speaker: And, you know, and we will and we will make that happen. We really anticipate this getting to be a lot of fun. We don't anticipate this to, you know, our biggest goal is to not talk over each other, um which is my biggest fault in life. So, um you know, I say the biggest thing is let's just have a lot of fun. And what we're going to start off with is we're going to have everybody kind of introduce themselves. And i'm going to let Therese take over from here because she's she's the woman of the hour here. Yes, that's me.
Speaker: So we're going to start. I'm just going to Max is just going to be um recording as we're going. As a matter of fact, he is right now. So I'm just going to start because you'll understand. So what we're going to do today is we are going to introduce each other to each other.
Speaker: And what I would like you to do is tell us your name, the role that you have in the space where you're working, the care setting that you're representing, and then maybe one sentence about where you see most often wound care transitions succeed or fail in your specific setting.
Speaker: Okay. So, Annie, we're going to start with you. Sure. So my name is Annie Harris. I am the administrator for a skilled home health agency partners in home care. um My background is in occupational therapy and I've been in various leadership roles. um in long-term care and home health for about the past 15 years. I'd say my experience where care seems to break down is um so it's it's right at the transition maybe from hospital to home or, you know, another setting to home is if we're getting all of the referral information quickly and it's pieced together and then the patient has all of their needs set up for them at home by the time they get home.
Speaker: And then that's where home health's job is to come in and and look at all those pieces and parts. Right. Yeah, I'm sure you're gonna have a lot to tell us in this discussion. um Jen, you're you're representing ah acute care. So tell us a little bit about...
Speaker: your Your background. owner Keep it super low. um I'm Jen. um Jen Beerhup. I'm representing post are acute. i I have done discharge planning, care coordination in the acute space um for about a a couple of years. um We had a pretty active home health, or excuse me, a pretty active wound care center. And so we get a lot of it wound care admits. And i was the I was the one that was the one that did all the discharge planning for all of the wound care um patients in the hospital, amongst other obvious discharges. We also were utilization review there. So I did all the interqual and MCG and um decided if they were inpatient or OBS or what did they qualify for. So I have um um that piece of knowledge as well. And I've also opened up an inpatient wound care center as well. So I'm here just to be the acute space holder.
Speaker: Very good. Thank you. Karen? Oh, I am Kieran Bauer. um As it was pointed out, I've been in wound care since 1932. I've been doing this a long time. So um I have the experience in the post-acute care setting, nursing homes.
Speaker: um But my main role has been directing an acute and outpatient hospital, outpatient department wound care center. um I think that where care breaks down is every single handoff.
Speaker: um You know, I think that hopefully we can kind of get in tonight, even in the outpatient space when i say I'm, you know, i I do a lot of vascular stuff. So if I want to refer a patient to infectious disease, even um just that referral, that care transition there, there's oftentimes breakdown. So I think that anytime that there's a transition, be it from inpatient to outpatient, outpatient to home care, whatever the case may be, there's opportunity for breakdown. And where I think that we can focus on success is our interpersonal one-on-one communication.
Speaker: i think that the relationships that we build are really important in that. And then wanna throw in there things like AI and machine learning for our discussion later because it's hard to rely on individuals, but I'm excited to be here.
Speaker: Thank you, thank you. Janine? Thank you. Excited to be here too with all of you ladies and having this conversation. I'm Janine McGuire, I'm a physical therapist by background I spent about seven years in burn unit, outpatient wound center acute care, and in the last then another 23 in skilled nursing, nursing homes, assisted living across the country and building their wound teams.
Speaker: And the last couple years, president and co-founder of the Post-Acute Wound Skin Integrity Council, and I work as a consultant and advisor for different wound provider groups. and so The biggest area of breakdown, i agree with everything that Karen said and everyone else.
Speaker: And what I feel is true is that those particular points of breakdown in every single handoff is not because every single one of us don't want to do a great job for our patients, but there really is and this there's a perception issue with wounds when patients are going through transitions of care, maybe not understanding the level of importance that that wound actually has and the issues it can cause. And the focus is on other things that seem like they're higher priority.
Speaker: But at the end of the day, it's the wound that ends up that, you know, causes the infection and then they're back in the hospital. So I think it's a perception issue. I think it's an education issue. And from my experience in building wound teams, oftentimes team members don't understand each other's roles on that wound team and what that means at that transition to convey the right information to the next starting
Speaker: I'm sure we'll elaborate more. yeah Oh, yes, we will. That's why we're here tonight. And Melissa, tell us a little bit about yourself. Melissa Melissa Ramdas. I'm a nurse practitioner for about 20 years now. I am independent practice in New Jersey.
Speaker: I see patients mainly in home care and in assisted living facilities. And I would say my biggest challenge with transition to care has to be with the acuity and resources that are in the hospital setting and them just not being the same in the home environment or assisted living and having to um get creative with trying to um do things like multiple dressing changes when you need to do that or having supplies or that may not be available in those settings that are available in the hospital setting, those kind of things.
Speaker: Yep, that's a big hiccup for sure. So it's pretty exciting because we have some phenomenal people here tonight that are representing each of the spaces that we see in post-acute care.
Speaker: So what we want to do is we're going have a discussion. um I'm going to have a couple of things I'm going to put out there. I might ask a couple of you to answer, but I would like all of you to contribute when you see a need or you want to say something. So this is going to be an open discussion more than it is, you know, a panel or we're going to pick on people to answer a question. so Okay, so let's get to know each other a little bit, okay? So when a patient enters your particular setting, tell me what you're responsible for, what's commonly misunderstood about the role in your setting that plays in wound care, okay? So let's start with Karen.
Speaker: What would you say, like, what you're responsible for and which you what's misunderstood about what you do?
Speaker: That's a great start and a really kind of ah a deep question. So in the hospital outpatient space or in the outpatient or ambulatory space in general, my perception, and it may be because of my experience, is such that I am responsible for figuring out what happened before me um and what is happening concurrent to me at that moment.
Speaker: um So I personally am a big believer in talking to the patient, getting records, having somebody really look through them, what studies have already been done, and how does the patient feel? Having said that, I think that I have a unique perspective in that.
Speaker: And i think that the challenge is that oftentimes in the outpatient space, similar to others, we feel busy and potentially under-resourced and tend to look at things from right now.
Speaker: And we forget to ask the patient what happened before. We don't get the records. We don't look at the MRI. Patient comes in and we deal with, okay, they're in our clinic right now. And then unfortunately, that care transition after the clinic visit is similar. Whereas I believe that I need to follow that through, call the home health nurse, figure out what's going on. Can we get supplies? I may want the dressing changed every day. And Annie's telling me like,
Speaker: no, ma'am, you can't. And I'm like, but I want to. And she's like, you can't. Right. So like having those conversations to figure that out. But I think so often we don't understand each other's perspectives and we don't meet in the middle. We kind of stay in our like, well, I need this. Well, I can't give it to you. Well, I need this. Well, I can't give it to you instead of realizing that all tides, all tides, raises ships. Well, that's saying like, we're all going to do this together. um You know, so I think that my role should be very comprehensive.
Speaker: In reality, I think it ends up being point of care right now. This patient's in the clinic. My job is only when the patient's in my clinic, they leave my space. People think, okay, out of sight, out of mind until next week when they come back.
Speaker: So I think that that's a challenge.
Speaker: Absolutely. Absolutely. And Melissa, where do you see a mobile wound care fit into that, that continuum where the patient has that, you know? Yeah, I would say I would consider myself like the cleanup.
Speaker: you know, just cleaning up any loose ends and tying things together that were missed or forgotten. um You know, whether it was like a pressure relief surface that that person wasn't sent home on or not um knowing the social issues that person is dealing with at home that complicate the wound.
Speaker: So there's, um it's just a cleanup that has to take place. And the only way to do that is by going to the home and really seeing everything and understanding everything from the root and then tying together what happened in that hospitalization and then coming up with her whole new plan to manage them.
Speaker: Right. And looking at what's going on in the home, right? Because when a patient comes to your, and and I know Annie, you've got a lot, I'm sure to say about that. You know, it's like there's a lot going on in the home that other other spaces may not even understand.
Speaker: So that's a good segue, Annie. What do you think? Sure. Yeah. So I think, you know, As Melissa is, you know, home health, we're uniquely positioned because we get to see the treatment plan in real life. So, you know, we're that the eyes and the ears and the connectors of that care. So I think the misconception for home health is that we're just providing dressing changes. You know, what we're doing is, you know, again, seeing that treatment plan in real life and is the patient, you know, we're looking at the clues in their home. Are they offloading appropriately? Do they have enough caregiver support? Do they understand what the recommendations were on their plan of care?
Speaker: um So if we are doing a really good job at communicating, these are great details that we can share with the provider, you know, to help make better choices and to help um that time in between provider visits as well.
Speaker: Yeah, that makes sense. And Jen, I'm curious, coming from acute care, right? So what what decisions are being made before the patients are even discharged, right? And what may not be available to you? Ooh, lots.
Speaker: You know, one of the biggest things about acute care is that you're highly focused on the reason why they're there. And you're stabilizing that, right? And that may or may not be the venous leg ulcer.
Speaker: It might be something else. It might be an exacerbation of CHF and they have a venous leg ulcer. Our main focus was CHF. We are still going to probably send them to ah home health, but we may not ah communicate or even focus on the venous leg ulcer.
Speaker: So now they're going home or they're getting these skilled cares connected for all these other disease processes that are absolutely leading to the venous ulcer, but the venous ulcer was never actually talked about anywhere. And then Home Health walks in and they're like, well, what is this present that I just walked into? This was not on their community referral form. And this is a whole new, well, now maybe we need. Like working a crime scene. Right? So, yeah. That's where the biggest thing is, is that we get so hyper-focused on that diagnosis of why they're there. And it truly is, you know, get the butt in the bed and then get the butt out of the bed. So, you know, we are really, it's really pressured to get those patients out as fast as we can, which is a great disadvantage, especially for our super complicated wound care patients.
Speaker: Yeah. Well, that makes sense. Janine, I know you got something to say about this. Yeah. Well, hey skilled nursing, the nursing home space is so regulated.
Speaker: and on one hand, it's amazing because we have these regulations. So there's somewhat more of an expectation of standard care. The other thing is we have every discipline just about or the ability to refer out under one roof.
Speaker: So there are some real advantages. The downside is that on that admission, here's this poor individual who just had a serious medical issue or issues that landed them in the hospital.
Speaker: They've exceeded that three-day stay. Now they have to come spend some time in skilled nursing. What we need to do as soon as they get there or shortly thereafter is a full body skin check. So if you just imagine being that patient for a moment,
Speaker: Now you're in a nursing home and now these strangers are looking at your body head to toe. But we all know the biggest predictor of having a wound is having a wound. So if you already have one on that admission, we need to make sure you don't have others and usually more than have to.
Speaker: And they're not in that hospital record. So we've got to scour that hospital record at discharge, find any indications of skin impairment or risk and on admission, full body skin check for every wound, a thorough wound assessment.
Speaker: And please note, it's usually by an LPN. And so they are collecting the data. That's the assessment. they're collecting the data, the measurements, the tissue types, and so on. And then that RN needs to review it and complete the assessment.
Speaker: Then they call the provider. to get the diagnosis and the orders. That all has to happen on admission. And it's crucial that it's accurate because let's say that all of us are the wound team in this facility. We do that skin check and we say this patient has a pressure injury. It's a stage two.
Speaker: And we say there's fluff in it and there's some depth. So we have some issue with our assessment. And then tomorrow, Melissa comes in and she's going to evaluate the patient from a provider perspective and says, this is clearly not a two. This is at least a stage three.
Speaker: If we don't use imaging, we're not using ai then the question is from day of admission to the next day, was there a decline in the womb? Because that's a potential time. Or did we not know how to assess?
Speaker: also a potential type. So on that admission, that skin check, the wound assessment is a requirement. And then we have to make sure the treatment orders are sound and according to manufacturer insert.
Speaker: So even if the hospital had something creative, we can't do creative. It has to follow the package insert to the T and Medicare guidelines if we're going to get reimbursed.
Speaker: And then we have to have all the interventions, the right bed surfaces, according to that facility's formulary. Because if you're ordering a particular brand, it's going to take us days to get something that's not formulary, that we don't have a contract with.
Speaker: So have to get the bed, we have to get the turning, we have to get the dietician, we have to get the heel offloading. All of that needs to be upon admission and start that care plan. So it's good. It's good work, but it is very difficult on those facilities that have a lot of admissions that are high acuity with multiple wounds. And often what we see in the hospital record, not often, sometimes what we see in the hospital record does not match what we see on that person.
Speaker: So it does put us both hospital and nursing home really in a sticky spot. I think that's got to go for home health and even a patient, right? If when you get these orders or patients that are discharged from acute care and there's discrepancies.
Speaker: I think we talked about that, that though sometimes that is the discrepancy or the orders. So, you know, yeah yeah, go ahead. Yeah. So, yeah, we have to have, i mean, it's similar to long-term care. So we have to capture, you know, the right,
Speaker: on coding and things on that initial oasis that we're completing. We don't want to own a wound that, you know, we didn't cause. So we need, you know, proper paperwork to back up what we're seeing. Everything that we do has to have some kind of, you know, physician practitioner documentation to support what we're doing. um You know, it it goes down to even billing practices. If we don't have the correct information on a face-to-face, we're not going to get paid for what we're doing. so you know, having the right information from the start, that's correct, that's coded appropriately and, you know, speaks to exactly what's going on in a patient is really important.
Speaker: um And we spend, there's a lot of administrative burden, um you know, getting that paperwork and making sure we have all the pieces and parts. Yeah, that makes sense. And that's ah that's what we're talking about next is reimbursement, because every setting that's represented here has a different way of being reimbursed, right? So, um yeah. So what we want to know is how reimbursement affects each of your settings in the treatment choices that you may do. um supplies that you may either have have available or that you can order, your visit frequency, because that's another big one, um referrals, how how the referrals can come in, and your ability to follow the patient over time. Because like I said, it's different in each setting. So Jen, I mean, in in in acute care, you know, it's it's pretty cut and dry, right, on how you do that.
Speaker: I mean, yeah, they're it's pretty cut and dry. um Obviously, when it comes to billing, we're a little separate because it's a hospital setting. It's an acute setting. So that's just like a very different animal altogether, depending on what their payer is, you know, or do they fall under a DRG, that type of thing. um So in the acute setting, it's just it's very, very, very, very different. And, you know, we do everything we can to try to so get our patients what they need before they go home.
Speaker: But, you know, unlike Annie and unlike Melissa, you know, we really don't know. And we've seen them for like three days. You know, we really just don't know exactly what's going on. And so we're kind of at a disadvantage. Yeah. of being able to we understand. And also like ordering certain things like DME, it's difficult um because our hospitalists, they don't want to sign that order. It's not their ballgame, right? And technically when you go to send that order in, they're still admitted, which becomes an issue. And so like we struggle, we can't get certain things. There's timing pieces to that. So, you know, you always say, well, why does hospital not order all these dressings? Well, we really can't.
Speaker: Like we just can't do it. And anymore, you know, i mean, heck, I mean, 23 years ago, we'd have five dressings sitting in the in the in the in the room and we'd send them home with the patient because that's what we did. And, you know, that's just not happening anymore. So really our patients are coming home with nothing, like almost no no dressings from the hospital setting. um And I know that Annie can probably really speak to walking into a house with absolutely nothing. And so can Karen and so can Melissa. So um That's from an acute perspective.
Speaker: How do you see that in, in ah so I used to do mobile wound care myself. So Melissa, I'm curious to hear your point to this because it is a struggle there too. Yeah. Well, for, in terms of reimbursement from a provider perspective, there has to be a reason why a provider's there in the first place. You can't just go in there just to change a dressing.
Speaker: um there's got to be some evaluation, high level, provider level, you know, management reason, whether it's ordering labs or getting wound culture or ordering um nutrition supplements, um whether it's protein supplements or vitamins, there's got to be a reason for that. And that justifies the reimbursement. So I think that's where, what probably the challenge is, is why am I here? Am I here to debride this wound or do something that um the nursing team, the home care agency is not able to do.
Speaker: Yeah, that makes sense. That's where my head is when it comes to reimbursement. Yeah, that makes sense. Karen, what about the outpatient clinic? How does that fit in?
Speaker: um It's a lot. And I think like, as I'm listening to you guys and just like my experience in the other settings, you know, I think about any, your regulations and Janine, what you mentioned in the skilled facilities and mobile.
Speaker: And I'm like, man, it's a lot. And they're also different, right? Like just hearing you guys talk, I think, you know, before I like specifically go into the HOPD, it's, I think that too often we let perfect be the enemy of good.
Speaker: So like Jen, hearing you talk that like when we make dressing decisions and Janine, I think you actually did a lecture on this, but like when we make dressing decisions, it can't just be what do I like or what does the wound look like? We have to think about what setting are we in What can we feasibly do? Where is this patient going and not letting like, yeah, when the patient's inpatient, Jen, you might want, you know, ah a collagen and an algeny and a foam change daily on a patient. right But you have to like you have to adjust that.
Speaker: um But, you know, I think, Melissa, you hit the nail on the head with the the outpatient clinic. You know one, we have a hospital outpatient department, and then we have physician clinic. So the two clinic settings already themselves are very different.
Speaker: They're reimbursed differently. we have different regulations. So you you have to understand if you're in a true hospital outpatient department, how your clinic's set up. um Even where I was initially, i was in a hospital outpatient department, but they didn't know that. So they had set it up on the back end as a physician clinic.
Speaker: or provider clinic, and it took us almost a year to get our billing people to understand that this is a true hospital outpatient department. So I think that's one thing. But Melissa, you mentioned the medical necessity, and that's huge in the outpatient space as well, that So often we want these patients to be able to come in just for dressing changes, right? If they can't get home health or they don't have a mobile wound care provider, um we have to be very careful with that in the outpatient space because one, if a provider is seeing the patient, you have to have medical necessity.
Speaker: And then in our space, similar to others, you have is this evaluation and management. Am I making clinical decisions or is this a procedural visit? The cellular, acellular products, the debridements, things like that.
Speaker: And you can't build those things generally together from a provider standpoint. So there's lots ah of nuances and there. And I think that the big thing right now, of course, that's happening, especially in the outpatient space are the cellular, acellular matrix like products.
Speaker: um You know, I think it's really important when you're in the outpatient space to understand your Medicare is subsidiary, to know your LCDs, to know what you can and can't do in your clinic. um But I think the most important thing when it comes to reimbursement in the outpatient clinic is documentation.
Speaker: And I think that's where we oftentimes fail if we don't have a wound specific EMR. So I've been in clinics where we have a wound specific EMR. And, you know, at the time I'm like, oh, this is so cumbersome. I can't. But now that I've been in clinics where we don't have the wound EMR, I'm like, wow, I had a good. yeah Because the regular EMRs are not built to document the things that you have to document to capture what you need to capture to keep yourself safe legally and to get paid. Yeah.
Speaker: So I think that, you know, looking at the the cellular and acellular products and following the LCDs and documenting that is a good lesson for all of us. But it's it's probably one of the more challenging things that I experience.
Speaker: Yeah, I can see that. Janine, any comments on that or from the put from the post? I'll just share a little bit of about the, yeah, the skilled nursing or nursing homes.
Speaker: So when people first go for skilled, so that is people will refer as short-term rehab, that's generally 20% of the beds of any nursing home on average, give or take.
Speaker: And that payment structure is PDPM. So it's a daily rate on average at a national level, it's around 600 bucks per day. Out of that $600, that's paying for room and board, all the nursing care, all the specialty services, all the treatments, all the food, all the nutritional supplements, and so on, ambulance trips. So if we're sending a patient to a wound center, that ambulance is sometimes an $800 per transport.
Speaker: We've already exceeded the amount that we get to pay for every piece of care. So just please keep that in mind to that if you have a patient that needs skilled nursing,
Speaker: find out if they're good at wounds. Because if they have a good wound team, perhaps it makes good sense to allow them to internalize the care while they're on that short stay.
Speaker: And then once they go to long term, maybe it's appropriate to get visits to the wound center or discharge. We set them up in the community with a mobile wound group or wound center. Now, there is a caveat.
Speaker: If you are a mobile wound group provider, you can see that patient on part A and it's not typically going to cost the facility anything. So if there is a great mobile wound group in that area, it would be a real value add to that facility's wound program.
Speaker: But just a little bit to understand, they're paying for all the treatments out of that. So keep that in mind. Now, once they go to long-term care, if that person ends up living and that's their home, then it's just like living at home.
Speaker: In other words, the products are now billable to part two. So it changes everything, but the facilities understand that billing structure, even if visiting wound provider groups or outpatient wound centers do not understand, but it really does need to be understood because it shapes the type of care that's possible in those settings.
Speaker: Oh, absolutely. Annie. ah So we have um similar share a similar payment model to long-term care, but it's PDGM. And that's um for our episodic payers. So we are paid one lump sum for a 30-day billing period based on, you know, there's some different patient characteristics that go into that number. And again, that's to provide all of the services. So it's if they're needing any kind of therapy, any nursing visits, That includes our, you know, our supplies, our dressing supplies, our routine supplies, things like that. And then we also have to be able to show skilled need and medical necessity and that, you know, we're updating the treatment plan when things are stalling. Yeah.
Speaker: you know We also have to, we have you know Medicare Advantage plans, commercial plans, those are paid a little bit differently. That's paid per visit. though That's a contracted rate you know with the payer that we have. Typically, we're able to bill the insurance company, but what's covered can always be different as well. And then what our rates are you know to send clinicians is different um based on you know which clinicians actually going out into the community.
Speaker: And again, we have to show that medical necessity and that skilled need. Some of the payers now require that we, um you know, work with a case manager that's specific to the payer. um There's a lot of companies that have wound programs now. So we're speaking to typically least a nurse practitioner. We're going through the patients that are on caseload and they'll actually say to us, okay, you've been using this dressing type for x amount of days. um You know, can you go back to the provider, try something different? And then, you know, they'll actually reach out to the provider and the patient as well and give updates.
Speaker: Yeah, that's that's great. So, you know, we' we're we're all here from different settings. So I'll let you think about this because I'm really curious if you could require three pieces of wound-related information that would travel with the patient between settings.
Speaker: What would that be to help you in your setting better understand like what was going on, maybe what happened, what needs to happen? is there anything you could think of that might be beneficial from where you sit in the setting where you're at?
Speaker: And shout it out. Yeah. arms Dressing orders. Do they have the dressings in the home? Measurements and and and photos and offloading and what's been ordered. So it's fine because again, you know, we'll be part of connecting that care. But, you know, patients need a lot of help to make sure that they're getting the equipment that that they need. So what's been ordered, what hasn't and how can we help?
Speaker: That's a good one. That might be than three. That's okay. There's more we all wish, right? We want the whole thing. then actually, we also need the whole big picture. So sometimes, you know, like...
Speaker: We want to know, of course, about the wound, but then we need, you know, primary care information and specialist information as well. Because that's another, you know, detective work, you know, figuring out who else is involved involved in the patient's care. Annie, you're asking for a lot. Okay, I'm done. All right, Janine, what you got? Okay, so the one thing we see in the literature is that the misdiagnosis rate of wounds, 30%, 40%.
Speaker: forty for cent In my experience, it's even higher. and so if I could have one thing, it would be that we're required in every single setting to have wound images and that they go with the patient always.
Speaker: And that way we can get some degree of consensus on accurate diagnosis. So that would be number one. Number two, vascular status. So that we should be checking vascular status of every single patient. And that's something that is so often missed. And yet we just continue to go down this track of, oh, well, the treatment A didn't work on the heel wound that has no circulation. So let's try treatment B. So we are not doing the foundation work.
Speaker: And then the third would be um similar to what Annie just said. I need the bigger, we need the bigger picture. We need we need the full laps. We need any imaging that was done. We need to don't know deeper to understand what we're really working with to see if this individual is healable or if it's a maintenance. So what's really going on? Because we set ourselves up, at least in my space, for failure so often when we don't have all that information and we're telling people they're going to heal. And when they're when they're not, we just focus on a topical bandage. We're part of the problem.
Speaker: So we need to start diving deeper. o I like it. You're not wrong. Melissa, what do you think? I would want to know the onset date. when When did this start? Because that's always, um could be choppy, um depending where you get um your referral from and where the medical records, how far back you go. Sometimes patients don't recall. They've had multiple wounds and they don't remember where when which one started when. because that's going to change my treatment plan and how aggressive I am with it.
Speaker: And I would want to know failed treatments. What has failed? So I don't repeat the same mistakes or we don't just keep trying the same thing that's not working. And then i I definitely would want to know who's touched the wound in terms of if there was any surgical intervention or if there were other wound care specialists, podiatrists, or who's been managing it.
Speaker: Absolutely. Because that tells me a lot about how, you know, if it was just maybe an urgent care center, we write different than somebody who's wound certified. Good point. Yeah. right, Karen, I know that Janine took your vascular study away from you there. was That was so good. and i'm i'm glad, honestly, like so often, you know, i i'm I'm vascular passionate. Like I just, i I just love it. So hearing someone other than myself say that is just music to my ears because again, so like,
Speaker: 100% what Janine said, number one, I want the diagnostics, but specifically the vascular diagnostics, because like you said, so often we're treating these wounds. And like, I just saw a patient in clinic the other day that, and I'm a vascular person, right? Like I'm not in a vascular role right now.
Speaker: but I'm treating his VLU, his venous leg ulcer. And I've been seeing him for like two months now and I don't have access to his records. I don't have access to his studies. I don't have access to anything. He's got a great pulse, but I just found out like yesterday that he had had multiple revascularizations.
Speaker: And I'm liking and wow wow i like, Like, don't have You just found that out. Just found it out Like, I don't have access. There's two different yeah EMRs within our system. So in the clinic, we use...
Speaker: one and the vascular team uses the other. I don't have access. And we don't have an oftentimes in our clinics. um Again, that point of care, oftentimes our support teams are right now, they don't understand why vascular status matters. They don't understand what an angiogram is.
Speaker: They don't know those questions to ask, right? So that's my soapbox, vascular studies and diagnostics. I want to add um medications. I like, it is huge to me to do a really good medication reconciliation in the outpatient space.
Speaker: Because Janine, to your point, like we're so often missing contributors and atypical factors and what the primary etiology is. You know, if this patient's not taking their p Plavix or their aspirin or their Eliquis,
Speaker: And they've had revascularizations. What better point to catch that than the weekly visits that we have with these people, right? So like, if we could have every patient carry around an active real time list of their medications, that is like a window to their wound soul.
Speaker: I love a good medication reconciliation. And then the third thing would be, Melissa, I think you kind of touched on this and Annie too. um In our outpatient space, we so often miss what is actually going on. Like the patient's gonna come in and I think Jen and Annie, I think we've had patients that we share with this where like Annie will be texting me like, Karen, like you realize this guy is like,
Speaker: you know, urine saturated dressings or walking on his foot all day and the patient comes into me and they're like, Karen, i don't walk at all. have my own fling boot on all the time. i never eat cookies. Right. And then Annie's like, wait a minute.
Speaker: Yeah, he has a bag of cookies by his bedside. Sure. Yep. It's bad cup, good cup. yeah So like knowing what's going on in the home for me in that space would be the third thing. Like I want to know what their life looks like outside of when they come into me and are like, yeah, I don't smoke. And then they're lighting up on their way out. Yeah.
Speaker: but but Oh, my gosh. I have to. Karen, I love that. Oh, my goodness. Only because hospital outpatient-based, that is my love. And, I mean, Karen, we have to communicate with home health. I mean, I feel like there needs to be some kind of something built, right? something Some kind of standardization of communication between hospital outpatient-based mobile wound and home health. Because it's like, and and i'm i'm in poor Janine, I'm like leaving her out. Sorry, Janine, like you're kind of over here in like this little odd land. We're used to it. um
Speaker: Like a little, I'm you're like in this little odd land. but But, you know, I mean, so we've got we've got like the trifecta, right, of people that can make a difference. We've got the trifecta. We've got the hospital outpatient base. We've got the provider that can go into the home. and actually write the orders ah when they're actually physically seeing what's happening. They can write the orders and make it happen. And then we've got the people coming out multiple times a week that can do the education, that can reinforce what what Karen discussed inside of of the center, that can continue to work on smoking cessation, that can continue can continue to work on helping the patient get transportation to their vascular studies that they need to have. And and so what I'm seeing is I see all these spaces and all these possibilities And it's not working.
Speaker: We're not really hard to get the information across. Right. So like we have it, but what are we doing with it? So yeah, we might know all of these things that are happening in the home, but how do we let wound care now? And what's, you know, how do we make sure that message is getting to them? We're typically not in the same systems. You like it makes more sense to use technology that we're all looking at together, some kind of AI so that we're constantly communicating. and that's where we felt, fail the patients, you know, things can be going south and I can reach out. But if the provider can't get the message and can't, you know, give us some guidance, then that doesn't help.
Speaker: So hot take. I think we often blame each other too, which is not good. yes So like oftentimes I hear in the clinics, like, oh well the home health nurse said this, or all the extended care facility nurse said that instead of working together having Janine, in your spaces, like we had advanced practice providers that we sent into the extended care facility from our tertiary center right so that the patient couldn't escape us. um But I think too often we have the mentality of like, why aren't they doing this? And why do I need to send them this? And this you know I don't have time to do this. Instead of realizing that like it is about the patient.
Speaker: So, you know, our systems don't work for us right now. We don't have the AI. We don't have the documentation. We don't have the funding. Nothing is standardized. We don't have checklists. So in the interim, how can we better work together instead of, you know, kind of passing the buck or saying like, you know, Janine, why didn't your nurses do this? It's how can I help your nurses do this?
Speaker: Oh, yeah, I love that. Oh, my gosh. I burst saying i absolutely love that. Yeah. Yeah. And, you know, i I was the same way when I worked in acute care and outpatient talking about the nursing homes and pointing fingers until I went and worked in the nursing homes. And was like, oh, wow, now I'm going to point the other direction.
Speaker: But you're right. You know, we really have to communicate. and We need better communication tools across all the different settings. But I think the the bigger issue and the cause is that we all know that wound care isn't a specialty and so it's not a recognized specialty so it's not raised to the level that it needs to be across every single setting and there's either an expectation that oh all nurses know how to do wound care or there's finger pointing that nobody knows how to do wound care but
Speaker: The answer is usually you know somewhere in between. But I think amongst ourselves, amongst those that are active in the wound care community, we we are we have the responsibility to try to figure out how to raise wound care up to the level it deserves, the attention it needs.
Speaker: And hopefully that's going to happen with AI. Hopefully it'll happen with value-based care. Hopefully. Who knows? Hopefully. Hopefully. Hopefully. hopefully So I have to tell, although hold on a minute, I have to tell a story. I have to tell a little bit of a story. And because I've, I mean, I've i've kind of I've done everything but long-term care. So there's that. i i I'm not in Janine's world. But I we talked about we get mad at each other, right? Like we we blame each other for certain things. and And here's the biggest thing that I need to tell the mobile wound space.
Speaker: And I need to tell home health or out hospital outpatient based the the the home health nurse's car is not a clown car. They cannot just randomly pull out 450,000 different types of dressings. It just doesn't magically appear the back of their trunk. Okay. And then like, if you say, Hey, I'm, I, you know what? We need a, we need a culture, right? We need a culture or let's just say, Oh, wait a second. You know what? We're have to do a blood draw or something, but home health is on. And then you call them and they're like, okay, we're going to have to order the supplies. And you're like, why doesn't the clown car just produce, know, A culturette. Or why doesn't it just produce these things? And then, because you know what, I did it back in the day. like, dad, home health care agency.
Speaker: They don't know what they're doing. what do what You didn't even have that in their car. i mean, come on. Yeah. And, you know, the reality is, is like no, they don't have it in their car. They have to order these things for the patient. And there's rules. and And anyway, so I just wanted to bring that up because I cannot tell you how many times in all these spaces that they get so mad that you just can't magically produce an aleven or a specific type of foam. Why do they not have that?
Speaker: That's true across the board. I'm really glad you said that because the same thing is true in nursing homes too. There's more than like 5,000 skin and wound products, right? And I don't know if you've ever been in a nursing home, but Central Supply is like an itty bitty little pantry closet usually. And that doesn't even include all the specialty surfaces. So I think that's one thing we can start with is across the continuum. Let's just use categories, please, instead of focusing on brands. That would probably be basic start.
Speaker: Yeah. Oh, yes. Root cause of that, too. We don't have great research. So like, why do you want an 11 over, you know, whatever other brand name? And so like to not use categories. Yes, I have my preferences. I've seen anecdotally things work. There is research behind some things, but ultimately at the end of the day, there are really no head to head trials that say, you know, this is better than this.
Speaker: So I think considering that as a root cause as well, that if we are going to start to dictate, I want this product, we have to be able to back that up with science. right whatever that science looks like um but that's it's hard because it's like why do you want that one dressing Right.
Speaker: Right. I think we see that in every setting, honestly. So I think we have um people, ah you know, in our audience here that would like to know specifically how a scenario might be addressed by each of the spaces. So if it's okay, I'm going to give you a quick scenario, a patient scenario, and I'd like to see from your setting what you would do first. We don't have to go into a big, long discussion. I know we're kind of running out of time. Right. But I think this is something that could be put into, you know, what would somebody could actually use as they're listening to us talk. So we have a patient with a diabetic foot ulcer that's discharged from the hospital on Friday afternoon.
Speaker: The home health agency receives incomplete orders. The family does not have the prescribed supplies. The outpatient wound appointment is not for 10 days. And a mobile wound provider is also contacted.
Speaker: This is not an unrealistic scenario, right? So tell me from your setting, what's the first thing you would do in a situation like this? So Jen, they came from ah hospital, right? So what do you think?
Speaker: Diabetic foot ulcer, no supplies. you know the big thing is, is like, you know, okay, were they there? Did they have surgery? Are they now missing parts of their feet? or What are they going home on? um Are they going home? i mean, no, you didn't add this, but are do are they going home on IV antibiotics? Are they not going home on IV antibiotics? Do they have to be followed by ID? Do we need to get all those appointments set up um for them before they leave? Do they have a PCP?
Speaker: That's a big one. Because that's a really big problem. And that puts us in a really big conundrum for getting services like home health, continued things ordered. That's a real big roadblock.
Speaker: And so, I mean, I feel like I could talk for seven years on this. And and really from the acute space, it's... it did Yeah, I'm going to like, going to hand this off because I feel like I should just back up a little bit, and hand this off to like the next space. We can't even get started. you know, we have to have that complete order. So that starts, you know, we're investigating or talking to the patient, finding out if there's a PCP that will sign for orders in the interim.
Speaker: And then we're able to, you know, get an updated order, start some care, go with what our recommendations are until, you know, maybe they get into wound care. mobile group gets out to see the patient.
Speaker: But we need all of those pieces and parts to, you know, really start that admission. Melissa, what do you think at this point? So this patient, what what do you do it for this family? What do you do for this patient?
Speaker: I would prioritize them on my to-do list. I'd see them, you know, within the next 24 hours just to get everything going. get the orders in place and so the home care can move quicker.
Speaker: isn um Find out who that PCP is and um you know make sure everything else is just tucked away that needs to be addressed and then who's gonna follow up. What's the reason for the wound center um visit? Are they planning to do something so I don't do any due duplication of care? um And I kind of stay in my lane just to make sure we're all playing our roles.
Speaker: That's what my priority would be. yeah So Karen, this patient calls the wound center and they're like, I know I don't have an appointment for 10 days and this is the situation. What do we do? This makes me a very unpopular individual.
Speaker: I am bringing that patient to me that day, period, end of story. And if they can't get there, let's be real. I'm filling up my own trunk, making my own clone car and getting them what they need. Like, hey, can you know can we telehealth? Can you send me a picture of your wound on secure email? Can we talk about what your wound looks like? And let me see what I can pull up out of my clone car or my clone closet.
Speaker: I am building them a packet and asking a family member to stop by and pick it up for them until they can get in if they can't get in. um But I had a philosophy, especially in the vascular world, when we're looking at limb preservation, um and it's very hard to implement when you're looking at a lot of different things, but I wanted every single patient post revascularization to be seen within 48 to 72 hours in the outpatient center. Check the groin. Are they on the right medications? Look at the wound, look at the foot.
Speaker: Even post ho hospitalization in this setting. Why 10 days? Right. Like, I don't care how full your schedule is like we need to make our systems work for us. So my answer is I'm getting to that patient. However, I can get to that patient, you know, no holds barred because otherwise they're going to end a break back in Jen's hands. Right.
Speaker: Right. That's exactly right. And I think everybody on the call is going to want your phone number. I mean, that's kind of how we rolled. Yeah, it was. That was the best part of working with care. You know you made things happen. So yeah you helped fill in the puzzles and pieces and you know we could work together to get the care for our patients and instances like that.
Speaker: our systems are- No long-term care was- Yeah. Go ahead. Just that our our systems don't support that. It's sad that as individuals, we have to do that. We need to build those systems, but thankful for the people who help do that, right?
Speaker: That's true, but that says a lot about how we're doing things, right? When we have to rely on people to go outside of what the expectations are, right? So Janine, I know they didn't mention anything about long-term care. Yeah, going to speak about both ends of skilled nursing. So when we get new admissions, the recommendation from anybody, any of the listeners from skilled nursing is POSIC has the mobile wound group checklist.
Speaker: I would highly suggest if you don't have a certified wound provider today, Use that tool to find a provider that understands the regs of that space.
Speaker: So you want that expert and you want to engage with them for your new admissions with wounds and whatever other routine engagement. And then i would also recommend that you look at your discharge process because ah percent of those patients go to home health. They go back home. They're not all going to stay there for long-term care.
Speaker: And that you can change your discharge to actually do training of the dressings with the family before the discharge happens. You can find a wound provider, a mobile wound group that's in the area that can go to the home or make sure the wound center is set up the day after discharge because you have that wiggle room for planning.
Speaker: So really put some focus on what's happening with the patient's wound at discharge because I think that priority is often at the bottom of the list. and it needs to be up much higher.
Speaker: So that would be my recommendation for that space to improve that transition.
Speaker: Well, that leads us, were you gonna say something, Jen? I'm sorry. No, I mean, you know, I mean, I think what's I think what I get frustrated about is that, you know, I'm staring at a panel of tremendous providers, practitioners, agencies that have just developed amazing processes and communicate. And we know how important it is to do that.
Speaker: And I'm ridiculously passionate, especially about the communication piece. um I would call every home health care nurse for my patients. every Everyone, every time, every week that we saw them, I followed up with the home health care nurse. We don't give me in the...
Speaker: If I'm case managing Karen in a hospital outpatient base, they don't give the time anymore for us to actually do what we need to do after the fact in order to do all the follow up. They don't get it because now we're seeing the next 25 patients from noon to noon to five. And now and now we're prepping and wrapping like we're not actually case managing. We're just going in there now and now we're washing legs and. And we we did we did case, Karen, but now everything is is gone, right? and and And now they want to push more people in the clinic. and And we can't do any of that communication anymore. I guess my point is is in we have to so do something, right?
Speaker: it's It's going to continue to fail unless we all come together as the people that really have the voice,
Speaker: inlet We have to figure out how to fix at least one or two things between each space. Because if we don't, our patients are going to continue to fail.
Speaker: They're going to continue to be readmitted. And, you know, we all know this, right? They're going to continue to die. Mm-hmm.
Speaker: And so, I mean, I guess my challenge is, is that, you know, we're talking and this is why we did this, right? Is how can we all, what are we going to do? If we tell if we tell everybody what's the call to action here, right? Like what's the call to action from this podcast?
Speaker: How we fix this. I know that wound care is not a specialty. I get it. But holy, we we have got to be able to communicate better than what we do. And Karen, I think you hit it right on the head. It's all about technology coming up. I think it's a technology piece.
Speaker: But how do we do this? and And I'm throwing it out there. I mean, truly, I'm throwing it out there because we're all failing. We're failing across the country. Mm-hmm. I don't mean to be a Debbie Downer, but I mean, yeah it's global it's global. Not just the country. I'll look at worse.
Speaker: Yeah. And it is incredible how we all... m okay No, go ahead. I think the first call of action that I'm hearing, ah other than like other than those of us in this space really fighting for specialization, is also those of us in medical really...
Speaker: talking about the fact that skin is the integumentary system, it is an organ. We need to raise it to that level, that it's not just a little cut or sore that just needs a bandaid on top. This is an important area that causes a tremendous amount of suffering, re-hospitalization, amputation, and Jen, your point, death.
Speaker: So we need to make sure that people focus on every organ, including skin. Mm-hmm. Mm-hmm. Absolutely. And I think one of the things, not that we we don't have time, we're running out, unfortunately, I think we can go on for another four hours.
Speaker: But one of the things that I notice is like all this technology that is coming, you know, the AI that's learning, but it almost seems like we're developing it and still in our silos. You know, it's it's great that we have it for for mobile wounds or home health or, you know, you long-term care. we We all seem to be concentrating still within our own little set of what we know. And I think maybe a call to action, the bigger call to action might be as technology is developed, that it's brought together for the wound patient and where that patient goes. Not what we do, but where that patient goes.
Speaker: It's an idea. i'll agree with that. And I think also because there's so much litigation around wounds, I think we need to push for transparency as patients move on to the continuum.
Speaker: And I'm group thinking particularly for skilled nursing, you know, there are some facilities that won't permit imaging. That has to change. The patient has to come first. Yeah.
Speaker: I agree. Is that still happening? Is that still happening right now? Yeah. Still happening. Wow. It's crazy. Well, I got to say, this has been one of the the best podcasts. I mean, this is great to hear everybody's voice in post-acute care and talking about this issue because this is a big one.
Speaker: So I want to thank everybody for being on tonight. It was great hearing from everybody. Thank you. Thank you. Thank you. It was a lot of fun. Thanks.
Speaker: And that's a wrap on today's episode. Thank you so much for spending time with us. These conversations are why we do this, and we don't take it lightly that you chose to listen to us today. Before we head out, just a reminder. Everything you heard today is meant to educate, not to replace the advice of your own healthcare care provider. Please don't make medical decisions based on what you hear on this show. Your provider is the right person for that.
Speaker: Our guests share their own opinions and experiences. not the official positions of POSIC or anyone who supports this show. If you're dealing with a wound care emergency, please get to someone who can help you right away.
Speaker: And if today's episode was useful, subscribe and share it with someone in your corner of wound care. It helps us reach the people who need it the most.
