From the Editor: Practice Management 101
Because it is a clinically oriented publication, Ostomy Wound Management rarely addresses the business side of care. With millions of people experiencing chronic, nonhealing wounds – numbers that promise to grow with increasing incidence of obesity and diabetes – interest in the practice of wound care is becoming more focused. We would be remiss if we didn’t acknowledge the management of wound management, an entity (from individually provided home health care to nationally recognized wound care centers) that is thriving.
Most routine acute wound care (and probably, most chronic wound care) has been provided by clinicians in their offices or at the bedside. That paradigm is changing with the rise of the wound center model. Related literature strongly infers that outcomes improve when wounds are cared for in a dedicated environment of multidisciplinary experts, underscoring the rise of hospital-affiliated and free-standing wound care centers. Regardless of the in- or outpatient location, several issues need consideration, particularly when dealing with chronic wounds.
Who is providing the care? In every case (independent practitioners, free-standing wound clinics, and hospital-based centers), patients should be seen by physicians, nurses, and other professionals such as physical therapists specially trained in wound care. Actual provision of day-to-day treatment (eg, dressing changes) can be performed by less skilled clinicians, caregivers, and the patients themselves under the guidance of wound care authorities. Technical staff with specific training will be needed if a clinic offers additional, specialized therapies (eg, hyperbaric oxygen therapy) on its care menu.
Who is supporting the wound care effort? Ideally, all wound care centers should have a full-time Medical Director and buy-in from administrators – champions of the wound care cause. All staff, regardless of setting, should be regarded as resources in terms of knowledge of patient demographics (age and health) and ways to expand and improve both business and care.
Are people satisfied? Whatever the care setting, three groups of people should feel good about the wound care provided: the staff giving care, the patients receiving the care, and the referring physicians. Each group is aware of the other’s satisfaction. Expectations regarding coverage, timeliness, documentation, patient recruitment, skill and education level, continuing education, and possible board certification should be clarified regularly. A professional level of cooperation and respect heals more than just wounds. HIPAA also is part of the respect quotient; privacy policies must be established and enforced.
Evidence-based clinical practice guidelines should dictate all care. Many practitioners still follow old regimens because they are familiar and not because they are as effective as newer approaches, unnecessarily prolonging the healing process. Every wound care provider/operation should regularly review protocols and all wound care providers should be afforded continuing education, updating products and practice to keep pace with the growing body of wound management information. Manufacturer representatives can be helpful in this regard; while they want to increase their company’s bottom line, they also can acquaint practitioners with evolving and proven-effective products.
All care must be documented. Everything. No exceptions. Proper documentation helps ensure payment/reimbursement and forestall legal entanglement. Most importantly, documentation tracks treatment progress, validates protocols, impacts inventory requirements, and paints a realistic picture of business, not to mention what medically/financially does and does not work. Tools to link guidelines, outcomes, and data collection systems, as well as reimbursement guidelines, are available and recommended but old-fashioned paper charts, meticulously maintained, can suffice.
Space and Supplies
Wound care should be provided in a well-lit area with access to running water and basic instrumentation and supplies (eg, thermometers, rulers, cameras, gloves, dressings, trash cans). Someone or some system must be responsible for maintaining inventory. Home care clinicians may advise patients what to purchase; hospital-based wound centers often look to the hospital formulary for guidance and/or ordering guidelines. Requirements increase as wound care facilities become more elaborate – items such as dirty linen containers and hazardous waste receptacles (and the staff to handle them) are minimum necessities; technology such as hand-held Dopplers, low-frequency ultrasound, and pulsed lavage may be added later. Wound center resources will determine whether reusable or disposable equipment is a better choice, as well as the extent of office equipment such as copiers, fax machines, file storage, desks, and method of documentation (the more “electronic,” the more extensive the hardware).
Unless federal and state regulations (including the Centers for Medicare and Medicaid Services’ information), Joint Commission requirements, and coding and billing guidelines are understood, payment for care is in jeopardy. Individual practitioners up through hospital-based wound clinic administrators need to embrace and follow applicable rules in order to sustain business in this quirky healthcare environment. One may have access to websites full of explanations; technologically intricate systems exist to intertwine coding, levels of service, and electronic medical records. Nothing is better in any setting than someone who understands (and can “work”) the system.
A Word about Management Companies
With the scope and magnitude of care increasing, wound centers often are motivated to solicit the help of management companies. “Managed” wound care centers reap the benefits of a higher (and more experienced) authority handling the business side of their operations (including start-up activities and marketing) but may lose their autonomy to an overarching care/payment model.
Establishing a free-standing or hospital-based wound center certainly has advantages: one-stop, multidisciplinary care; being a link in the care continuum; the appeal of volume business. However, bigger business comes with larger concerns. There is much more involved – operational planning (front office and back office issues), clinician “politics,” and environmental considerations, to name a few – when the number of patients seen, clinicians on staff, and size of the care facility multiply. Business must never become more important than the original mission of those providing care– that is, to help patients heal their wounds. Management 101 teaches us that, no matter what the size or management style of a wound care practice, a patients-first approach with excellent outcomes is the only way to nurture a reputation for quality healthcare.
This article was not subject to the Ostomy Wound Management peer-review process.