Over the past several years, home care agencies (HCAs) have experienced an influx of patients who are more acutely ill and in need of advanced therapies. These patient scenarios often can be attributed to the stark decrease in hospital length of stay and the rise in chronic disease (eg, diabetes, heart failure, peripheral vascular disease) across all populations. Many patients require advanced and extensive wound care among other treatments; their wound care needs can exceed $1 to $2 million yearly. According to Nussbaum et al,1 chronic nonhealing wounds impact nearly 15% (8.2 million) of Medicare beneficiaries, far more than suggested by previous studies. Furthermore, conservative estimates for total Medicare annual spending for all wound types ranged from $28.1 billion to $31.7 billion.1,2
In an environment where health care dollars are stretched to maximum levels, HCAs must find ways not only to improve outcomes, but also to maximize the efficiency of the treatments they use. This sentiment is underscored by the passage of the new law and implementation of the home health reimbursement structure “Patient-Driven Groupings Model” (PDGM). The PDGM home health reimbursement system is the most significant change/overhaul for Medicare payment since the implementation of the prospective payment system in 1983. However, PDGM has an interesting and potentially beneficial reimbursement computation for agencies that are already (or willing to alter current practice in) treating wounds in an efficient, best practice, evidence-based way. The Centers for Medicare and Medicare Services (CMS) has effectively reweighted how wound care is reimbursed — if a particular agency can treat, heal/improve, and discharge patients with wounds in a timely and reasonable manner, that agency should see a positive revenue stream for taking on some of the most medically complicated patients.
Because PDGM so recently went “live,” home health agencies have time to begin implementing best practices, which include hiring wound and ostomy specialists (contracted or full time) and overhauling and stripping down supply formularies to contain advanced care products to decrease patient-visit frequency, concentrating on the most chronic and complicated patients first, and identifying intervention opportunities early in the payment episode.
Focusing on advanced wound therapies should be a major priority for home health agencies in 2020. Finding products that prepare wound beds by managing bioburden, regulating pH, stabilizing the microbiome, loosening nonviable debris, and reducing dressing change frequency will be the most valuable to any agency. The following study investigated the use of hypochlorous acid (HOCl) 0.033% as a topical wound cleanser in the home care setting.
Background. The Visiting Nurses Association (VNA) of Western New York (WNY) is a large HCA located at the western tip of New York State, encompassing 10 counties and performing approximately 500 000 patient visits per year. Approximately 14 000 individual wounds are treated per year, and yearly wound care expenditures can exceed $1.3 million.3
Methods. The VNA of WNY was introduced to a HOCl (0.033%) wound cleansing solution, (Vashe Wound Solution, URGO Medical, Fort Worth, Texas) in the spring of 2015. The product was trialed for 30 days to evaluate its ability to reduce bioburden in wound beds, improve wound bed tissue quality, and reduce healing time; HOCl appeared to help improve wound outcomes within the first few applications and subsequently was added to the VNA’s ordering formulary to be accessible to patients with insurers contracted with the VNA to pay for wound care supplies.
For the purposes of the VNA of WNY, HOCl generally was recommended for use on wounds with delayed healing, suspected bioburden, and moderate to excessive amounts of nonviable tissue. The manufacturer guidelines were followed for application: soak wound with Vashe-soaked gauze for 10 minutes, remove gauze, and proceed with prescribed wound treatment. Before this juncture, no VNA of WNY patients were using HOCl. In 2016, HOCl was used among approximately 700 (23%) of the 3039 patients receiving advanced wound care treatments; in 2017, 742 (year to date at time of study; 25%) of these patients were using HOCl.
Results. The driving force and impetus of the study were, first and foremost, the outcomes reported by the clinical field staff in the agency. After the first few weeks of trialing the product, the Wound and Ostomy department of the VNA took notice of the results. As more field data were compiled, the first substantial change noted was the reduction in the frequency of patient visits by 1.9 visits per payment episode (VPPE) for patients with pressure injuries for the first fiscal quarter, representing $154,597 in savings. The VPPE for patients with venous stasis ulcers decreased by 1.0, for a savings of $54,483. Annual savings projections based on these 2 wound types alone equaled $836,321.
A potentially overlooked and underreported metric for home health agencies is the average number of days between first and last order (ANDBFLO). This number can be useful for any HCA to calculate and analyze over periods of time. Deconstructing wound care supply spend data can speak volumes about an agency’s wound outcomes. Simply put, ordering less for patients over time shows improvement in outcomes, thus leading to a need for fewer products. An obvious note of caution in such analysis would be the need to additionally examine the agency’s rehospitalization or transferred to inpatient facility (TIF) rates of the same patient population to ensure the ANDBFLO numbers are not decreasing because of high TIF rates. In the analyzed time frame, ANDBFLO in the VNA of WNY decreased from 145 days in 2015 to 49 days in 2016 to 14 days in 2017. Inversely, the agency’s HOCl usage increased from 0% to 23% to 25%, respectively, among patients using advanced wound care products. Figure 1 shows that the average number days between the first and the last order fell sharply as adoption of the HOCl acid cleaner increased.
In addition to the highlighted metrics, the agency recognized an increase in healing rates for surgical sites at time of discharge (from 95.4% to 96%, 2016 to 2017).
Discussion. Multiple factors are involved in the healing of wounds (eg, clinician and patient education, patient comorbidities, and environmental concerns), making it important to control variables whenever possible. A fundamental part of the numerous multidisciplinary and multifactorial approaches to wound care is proper wound bed preparation to remove microbes and debris while simultaneously preserving healthy growing tissue. The VNA of WNY found that using HOCl 0.033% to prepare a wound bed was successful, cost effective, and efficient. Researchers4-9 have written extensively about the benefits of using HOCl in wound healing.
Conclusion. Because it was the only wound bed preparation product with antimicrobial preservatives to be added to the agency’s supply formulary in the analyzed timeframe, a correlation may be made between HOCl utilization and positive wound healing outcomes, as well as the significant health care dollars saved. ν