The Patient-Driven Groupings Model (PDGM), has outlined a move from the Prospective Payment System’s (PPS) 60-day episode of care to two 30-day billing periods within the 60-day episode of care. Each 30-day period is grouped into one of 12 clinical groupings based on the patient’s primary diagnosis. This primary diagnosis is the primary reason for providing homecare.
In the table below, these clinical groupings and the primary reason for the homecare services are described.
The wound clinical grouping is defined as those cases that fall into the assessment, treatment and evaluation of surgical wounds, non-surgical wounds, ulcers, burns and other lesions.
Starting Jan. 1, 2020, the Centers for Medicare & Medicaid Services (CMS) will offer top reimbursement for the care provided to these patients. Per CMS data, the wound clinical grouping is one of the clinical groupings with the highest reimbursement potential.
Wound care patients have never been easy to manage, and now the industry must work to achieve success with this difficult population within the limitations of the PDGM payment cycle. Not only are wounds painful and stressful for the patient, but time and money can also be wasted when the wrong treatment is provided or even if the same treatment is carried out for too long without success.
Financial Impact & Opportunity
The Agency for Healthcare Research and Quality states that pressure ulcers alone—just one common type of wound—can cost the United States health care system an estimated $9 billion to $11 billion annually. What this figure does not account for is litigation, penalties and the economic impact of rehospitalizations and health care performance measures. In homecare, it is imperative that clinicians manage these periods effectively, providing the right disciplines and treatment for the right wound for the right amount of time. These practices will not only help wounds heal but will also improve patient satisfaction and reduce rehospitalizations.
Under PDGM, it will be vital to focus more intensely on episode management best practices using evidenced-based care and implementing clinically sound operational processes for care management.
Steps to Wound Care Success
Home health organizations have an opportunity to prepare for the new PDGM reimbursement changes by developing a Wound Program of Excellence. Focusing on improving the care of wound patients will build an organization’s confidence not only to accept wound patient referrals, but also to market for wound patients from referral sources. Referral sources are seeking partners who produce the best clinical and financial outcomes. One way organizations can demonstrate this is by healing patients’ wounds in a timely manner without unnecessary hospital readmissions. Payers will be identifying and partnering with agencies who deliver the best clinical outcomes at the lowest overall cost of care.
Key Elements of a Wound Program of Excellence
The key components of a highly successful wound program that will produce excellent clinical and financial outcomes include:
- Comprehensive policies and procedures for wound care and skin integrity
- Evidence-based wound management protocols
- Standardized wound formulary by wound type
- Access to certified wound specialists
- Ongoing evaluation of staff competencies for wound care
- Wound metrics and outcomes dashboard for monitoring
Wound Policies & Procedures
The framework for a successful wound care program is established within an organization’s policies and procedures. Organizations must ensure that they promote an interdisciplinary approach to wound management that includes the patient, family, nurses, physicians, dietician, physical and occupational therapists and medical social workers. Policies should address wound assessment and documentation, wound management, skin integrity and skin risk assessment and should reﬂect the latest evidence-based best practice protocols. Include a video and/or photography policy if wound imaging is a required element of documentation.
Evidence-Based Wound Management
Organizations must ensure that their wound management practices are based upon current scientific evidence. Resources for the current evidence-based information include:
- Cochrane Database
- Wound Healing Society
- Association for the Advancement of Wound Care
- Wound, Ostomy and Continence
- Nurses Society
- National Pressure Ulcer Advisory Panel
- Agency for Healthcare Research and Quality
Also critical to implementing an evidence-based wound care plan is a well-documented and accurate assessment of the patient’s wound. In each case, wound documentation must include the following key assessment data:
- Wound type/etiology
- Pressure injury(ulcer) staging
- Wound location
- Wound measurements (length, width, depth, undermining, tunneling)
- Exudate type and volume
- Wound edge attachment
- Peri-wound skin appearance
- The patient’s pain level related to the wound
- Wound odor after cleansing
- Presence and grading of edema
All documentation should be date and time stamped. Wounds should be assessed at least weekly. Prompt interventions for wounds that show no progress after two to three weeks should include documentation that consists of the rationale for delayed healing and any contact made with the patient’s physician or other provider. Communication with the patient and family should also be noted, including all teaching and competency demonstrations provided.
Standardize Your Wound Formulary
There are several benefits to establishing a standardized wound product formulary, including improvement in wound closure rates, reduction in unnecessary dressing changes, formulary and dressing selections aligning with standardized wound management algorithms, and optimization of time between dressing changes. In developing standardized wound care, consider product quality first, cost second. This focus on quality will produce better clinical outcomes and an overall lower cost per patient.
Advanced Wound Dressing Formulary
There are affordable advanced wound dressings that are indicated for longer wear times and designed for heavy exudate, which reduces the necessity for frequent dressing changes—while improving healing outcomes and reducing the overall number of wound visits per episode.
By establishing a standardized wound formulary, organizations can streamline the products to meet a variety of categorical needs (absorbers, moisten lending options, autolytic debriders, skin protectants, antimicrobials, collagens, contact layers, etc.) while eliminating redundant products.
Access to Wound Experts
One of the key components of a Wound Program of Excellence is having access to a certified wound expert (certified wound ostomy continence nurse, certified wound specialist or wound care certification) to help manage complex wound patients.
Does this scenario sound familiar? ABC Home Health and Hospice hires a certified wound care clinician to address an increase in patients with wounds. This wound specialist drives over a large territory for the organization, making three or four visits a day on average. This person often accompanies the homecare nurse for educational purposes, effectively rendering the specialist’s time with the patient as nonbillable—and resulting in the agency using an expensive resource unproductively. When the census of wound patients fluctuates, the wound specialist may be asked to help with routine visits, leading to an expensive resource doing standard visits that could be done by a lower-cost clinician.
Another scenario may include the wound care clinician being over- or inappropriately utilized if there aren’t specific protocols for wound care consults. Guidelines for use of the specialist must be outlined and implemented by the organization for this program to be successful. Alternatives include hiring a wound specialist on a part time or per diem basis, contracting with an independent wound specialist, certifying current staff or outsourcing to a remote wound management company.
Routine Assessment of Nurse Competency in Wound Care
A formalized orientation and ongoing education program for wound management is essential for staff as updated processes and products are introduced.
At least annually, staff should demonstrate competency, including:
- Proper use and scoring of the Braden Scale
- Proper identiﬁcation of wound type and etiology
- Proper staging of pressure injuries
- Demonstration of proper wound measurement
- Demonstration of proper wound assessment
- The use of a variety of therapies such as negative-pressure wound therapy and therapeutic compression
Wound Metrics Dashboard
Specific metrics related to skin issues and wound healing must be the focus of the quality metrics tracked in a Wound Program of Excellence. In addition to closure rates by wound type, agencies should monitor wound-related acute care hospitalizations and emergency department visits.
The percentage of patients with new or worsened Stage 2-4 pressure injury must be monitored and reported to CMS through OASIS. Identifying high-risk patients via completion of the Braden scale should be initiated as a routine component of the nursing assessment and financial metrics should focus on skilled nursing visits per wound patient.
Efficient Episode Management Practices Drives Success in PDGM
While this article has focused primarily on how to successfully manage the wound care clinical grouping, the premise is the same for episode management for all clinical groupings. Agencies should be focusing on best practice episode management to prepare for PDGM and asking:
- Have we prepared our clinical managers to lead their teams to efficiently manage their patient caseloads? Do these clinicians have a clear path of communication?
- Does there need to be any further review of current agency practices and polices? Will current policies be effective in PDGM?
- Do any new agency policies, operational processes or best practice procedures need to be developed to guide us through the new guidelines and mandates?
- Have we thoroughly reviewed discipline utilization practices, visit utilization practices and resource management and are we providing appropriate ongoing management to ensure cost-effective care delivery?
- Are we coordinating care well between disciplines? Is there a process in place to develop plans together and shift visit utilization as patient needs change?
PDGM has provided homecare with a powerful stimulus to focus on improving episode management—and an amazing reimbursement opportunity that should encourage many to contemplate developing a Wound Care Program of Excellence.
The wound clinical grouping and the remaining 11 clinical groupings should be managed with increased scrutiny on strong clinical oversight, heightened awareness of utilization patterns, interdisciplinary collaboration that is effective and implementation of best practice operational processes as the foundation for building a clinical episode management program that will foster ongoing success in PDGM.