A chance to heal; home health agencies can improve patient care and increase profits with telehealth wound consulting - Telemedicine

Health Management Technology, April, 2002 by Nick DiCianni, Laura Kobza

At 2 p.m., a nurse consultant in a suburban Chicago office--a veteran Wound Ostomy Continence Nurse (WOCN) with years of specialty training and experience behind her--will guide a Seattle field nurse's examination of a pressure ulcer on the heel of a diabetic, homebound patient using a combination of clinical software and advanced telecommunications technology.

Telehealth wound care consulting programs offer a cost-effective solution for home health agencies confronting slow- or non-healing chronic wounds. The combination of video-conferencing equipment, diagnosis-specific clinical software and experienced wound care professionals has led to dramatically improved outcomes for agencies that have adopted telehealth programs.

Today's Exam

At 2 p.m., the Chicago-based WOCN witnesses the Seattle examination on her computer screen. Initially her view divides between an interactive window on the upper right and a software program that scrolls down the left. In the interactive field, the WOCN sees both the field nurse and the patient. Special equipment plugged into an ordinary phone jack in the patient's home allows the field nurse, the patient and patient's family to see and hear the WOCN in Chicago.

The WOCN instructs the field nurse in the removal of the old dressing. She asks the field nurse to zoom the camera for a close-up of the wound itself and, when the angle is right, clicks a button so the software can freeze the image for a screen-grab.

The output, a digital photo, will later be attached to the patient's file and stored in a database as an electronic file. As a visual record, the photo is invaluable to the patient's physician and impressive to agency auditors. For now, it shows up as a third window on the WOCN's screen, displaying the wound and surrounding tissues in vivid colors.

Those colors are important. With input from the field nurse, who collects the information and performs the measurements, the WOCN enters data corresponding to the 13 parameters of the AHCPR-approved Bates Jensen Wound Assessment Tool (BWAT).

The field nurse measures the wound's size and depth, evaluates the health of its edges and prods beneath the skin line to assess "undermining and tunneling." She then notes what tissue types are present, describes the exudate (drainage) and records the amount of fluid collected.

Next, she assesses surrounding skin color, notes edema, tests induration (firmness of tissue around the wound) and granulation. Finally, she measures epithelialization (how much new tissue or scar tissue has begun to fill the wound) and she also may describe the wound's odor.

Utilizing Data

Once the data is entered, the software generates a total score between 12 (basically healed) and 65 (very unhealthy) and recommends a standards-based care plan reflecting nationally recognized best practices.

The Chicago WOCN can accept the recommended care plan, or based on her own clinical experience, can customize a plan that reflects the patient's individual needs. This wound, which started with a total score in the 40s, is now scoring in the 20s and may heal completely.

In Seattle, the field nurse is a team player for the Seattle home health agency, but she is not a wound care specialist. Seldom has she been asked to note anything beyond the wound's size and drainage amount.

The care plan she formerly followed called for a daily dressing change. Unable to record any progress in healing of this wound, the agency, which for some months had dispatched a daily nurse at $75 per visit, had projected a loss of nearly $10,000 for this patient alone. Today, the field nurse visits the patient just once a week, and the wound is on track to heal within the prospective payment system (PPS)-imposed length of episode.

A wound that could have led to amputation is finally starting to heal, and an agency that was bleeding away its PPS margin is finally starting to profit.

Chronic Wounds, Cosmic Costs

According to a 1999 National Association for Home Care (NAHC) study, one-third of all patients in home care suffer a chronic wound, and at least half of those patients suffer multiple wounds. Unfortunately, the one-third with wounds incur more than two-thirds of the costs. From 70 percent to 80 percent of all home-health supply costs are related to wound care. The NAHC estimates the average cost of healing a wound at home (care plus supplies) to be about $13,000.

The cost of chronic conditions can cause home health agencies to lose track of spending, and leave them wondering why they can't make money in PPS. Because patients are rated in the PPS system according to dominant codes, a pre-existing condition such as diabetes may actually mask the financial drain on a home health agency--the cost of managing the patient's wounds.

To win in a PPS environment, home care agencies must control their costs and beat the clock. To beat the clock, they must heal the wound speedily. To control their costs, they must heal it intelligently. Either way, they must heal the wound.

The mandate to demonstrate healing within a specified time-frame puts extreme pressure on an agency's human resources. Even agencies with sufficient bench depth to dispatch a daily visiting nurse to deal with a chronic wound face disappointing results. Why? Counter-intuitive as it might seem, the answer is not a daily dressing change (demonstrating vigilance) using the cheapest supplies (demonstrating economy). The art of wound healing requires fine-tuning, which only an experienced WOCN specialist can provide.