The transition from the health care facility to the community is often fraught with supply issues. Discharge from the hospital may take place after daytime business hours or on the eve of a weekend or holiday. The supplies may not have made it into the bags to take home or were left in the transport vehicle; sometimes the ostomy surgery is performed at a regional medical center and the lack of supplies is discovered 50 miles later. People very new to living with an ostomy may discard usable supplies because they cut them imperfectly or run through their limited supplies due to inexperienced application technique. Patients may have pouch leaking issues that went undetected in the hospital because they had limited output, which changed when patients resumed eating normally at home.
The above occurrences quickly translate to small-scale crises because they cannot be easily remedied and because, without the ostomy appliance, the only recourse is towels wrapped around the abdomen, which is a very undesirable outcome. Obvious solutions are to prepare for these possibilities by educating patients and their support system of possible mishaps and by ensuring that facility staff take extra care at all junctures of the discharge to make sure the supplies get out the door with the patient.
Post-acute provision of ostomy supplies. For a properly fitted ostomy pouching system, ostomy appliances are selected based on the type of ostomy, stoma shape and os placement, consistency of output, body habitus and abdominal contours, and any impairments the patient may have (eg, problems with eyesight or hand mobility). Post-acute facilities and home care agencies that accept patients with an ostomy are required to provide or assist the patient to obtain ostomy supplies. If the post-acute facility or home care agency does not use the same manufacturer as the acute care facility, they are expected to provide suitable equivalent products in a quantity similar to the approved allowable amounts. For the majority of patients, equivalent products that have been knowledgeably chosen and provided will be sufficient. For the patient with unique needs and a difficult pouching situation, poor communication of the needs and inadequate provision of products may result in peristomal skin damage and hospital readmission. For these patients, good communication is imperative among all facilities.
Prevention is the best solution to post-acute dilemmas. Post-acute facilities and home care agencies can learn what products are used by the referring facilities in their area. Contacting the regional manufacturer’s representative is a resource that often is overlooked but can result in acquiring product information, catalogs, and in-service instructions on product use. This resource can make establishing an ostomy supply stock much easier. Too often facilities and agencies do not design a cohesive collection of ostomy supplies and rely on leftover products. A well-designed supply stock and instruction in product use will result in decreased waste of products and wiser utilization of staff time.
Nonmedical switching issues. An example of nonmedical switching occurs when distributors of ostomy supplies change ostomy products that they distribute, often without consultation with the patient or medical professional. This practice suits business needs rather than patient needs. A company may, of course, make business decisions related to its circumstances, but unannounced changes by nonmedical staff are irresponsible. The consequence of this practice is that many patients may not be able to obtain their prescribed prosthetic devices and are unable to manage their ostomy effectively. Patients need to be informed in advance of a change so they have the opportunity to determine if an equivalent product is appropriate, consult with medical professionals for assistance, or determine if they need to change suppliers. If patients are switched to a product that fails to maintain system integrity, they may need a clinical consultation for instruction on the new product, assistance justifying the previous product, or identifying a new product.
Denial of supplies. Denial of supplies by the payer source is different from nonmedical switching. An appeals process accompanies any payer source denial (due process) and is the key to resolving the issue. Consultation with a clinician knowledgeable about ostomies for review of the denial prior to the appeal may help identify the problem and provide a solution (eg, a non-sting wipe may be reimbursed but a non-sting wand may not, or a specific manufacturer’s non-sting product may be denied but a generic non-sting product may be approved). Patients need to be educated that denial letters must include instructions about the right to appeal and that an appeal is the next step. The patient can also contact the insurance company’s customer service department for assistance with the appeal process. The patient should be prepared to explain the specific circumstances that necessitate the denied product (eg, the barrier ring is needed because it absorbs moisture and provides convexity to redirect output caused by an oddly situated os).
Copays. Another category of supply issues occurs when the high cost of ostomy supplies translates to patient copays. A copay of 20% on a supply bill of $1500 can result in a budget-busting expense. The challenge of finding less-expensive supplies is often overwhelming to a patient with a new ostomy. A clinician review of supplies with the patient can clarify what is needed on a monthly basis and what can be ordered less frequently and also can determine the most cost-efficient way to create convexity. Patients with high copays need to obtain cost estimates for their supply list from suppliers accepted by their insurance so they can make the most frugal choice.
Deductibles. Patients with high deductibles can shop from a larger range of suppliers, including low-cost options and charity sources. These options were discussed in a previous “Upfront With Ostomies” column.3
There is variance in the coverage of ostomy supplies by managed care insurance plans; some plans pay 100%, and some require a 20% copay or other copay amounts. A solution for people with managed care providers (Medicare, Medicaid, and Affordable Care Act) may be found by researching plans and changing at the annual open enrollment or special enrollment periods to a plan that offers better supply coverage.
Patients without insurance. Despite recent changes and efforts made to obtain insurance coverage for everyone, a population exists that has no coverage. Some large hospital systems have developed systems for subsidized/discount ostomy (and wound care) supplies through the hospital pharmacy for at-risk populations. This is often dependent on hospital funding resources for the indigent population. This resource possibility is worth exploring for patient eligibility. Some major ostomy supply manufacturers have programs to assist the uninsured. Local ostomy support groups may maintain supply closets of donated products and can be found through UOAA resource lists (ostomy.org). The larger charity thrift stores in some locations offer ostomy supplies, and there are also low-cost ostomy supply programs.3