Today’s Wound Clinic invited me to share the insights working in a unique wound management environment that may be a model for healthcare in general and wound care in particular.
I echo everything Caroline Fife, MD, enumerated in her recent editorial, “The Handwriting on the Wall for Wound Management,” in which she suggested that the Quality Patient Program and Merit-based Incentive Payment System (MIPS) Value Pathways (QPP-MVPs) could spell the end of wound management. I am on a journey to save myself as a wound management clinician.
I trained as a general surgeon with an additional vascular surgery year. Like many others in our field, the specialty of wound management found me, rather than the other way around, about 8 years ago. I am forging a path within our unofficial specialty, caring for a very sick and diverse patient population. I’ve practiced wound management at all levels of care including acute inpatient, long-term acute, and long-term care. I found my career home within the Program of All-inclusive Care of the Elderly (PACE), a “ground zero-think tank” for the QPP. The QPP could spell either the end or the true beginning of our field.
Medicare determines reimbursement for the PACE program using the Hierarchical Condition Category (HCC) risk adjustment model, which is used as a measure of relative patient sickness. In PACE, I am held accountable for quality performance by reporting QAPI (Quality Assessment Performance Improvement) metrics. QAPI is the coordinated application of two aspects of quality management: Quality Assurance (QA) and Performance Improvement (PI). The goal is to maintain and improve safety and quality, so the QAPI process takes a systematic and data-driven approach. The quality measures utilized are those usually reported by facilities (e.g., skilled nursing facilities).
Sadly, there are very few quality measures that are relevant to wound management (e.g., pressure injury prevalence and foot exams in patients with diabetes). I hope one day we can include the three wound relevant quality measures developed by the Alliance of Wound Care Stakeholders and the U.S. Wound Registry (USWR), which were also recently added to the Centers for Medicare and Medicaid Services (CMS) Physician Compare quality website. These quality measures are arterial screening of all leg ulcer patients, offloading of diabetic foot ulcers at each visit, and adequate compression of venous leg ulcers at each visit. Even without being required or able to report these measures, we have protocols in place to ensure we perform them.
As the PACE “Wound Doc” (a.k.a. the Wound Wizard), I have access to an interdisciplinary team that is the atlas of our care model. In collaboration with our operations leadership team, we developed a comprehensive wound management service line for our “participants” (meaning, our beneficiaries). PACE is the medical home for the participants and is in the unique position of being the provider as well as the insurer for participants. Participants have access to a full-service wound management program with certified wound care nurses and clinicians as well as certified lymphedema management specialists via our rehabilitation program. We coordinate care via weekly multidisciplinary meetings, which include nutritionists, rehabilitation therapists, palliative care nurses, primary care practitioners and day center team representatives. Every discipline has the opportunity to contribute to ensure that every participant with a chronic wound receives the most comprehensive, highest quality care plan.
I see participants every day with wound problems that represent the entire spectrum of skin and wound etiologies. I have access to the most comprehensive and cost efficient (i.e., low cost with a healing outcome) advanced wound management supply list, including cellular- and/or tissue-based products. I perform wound bed preparation (i.e., sharp debridement) and prescribe negative pressure wound therapy. We can provide electrical stimulation and low-level laser therapy (i.e., photobiomodulation) when appropriate. We provide all the durable medical equipment (DME) needed for wound management including compression garments (e.g., Circaids), compression stockings, lymphedema pumps, offloading footwear, orthotics, positioning cushions, and hospital grade specialty mattresses.
Within PACE, wound management services are as vital to patient care as nephrology and oncology, easily supported by the fact that my HCC score is the same as a nephrologist’s!
Chronic wounds are indiscriminate of age, gender, ethnicity, religion or creed, and place a significant financial and quality of life burden on patients and their families. Our patients live with a backdrop of chronic medical conditions like terminal cancer, multiple sclerosis, ALS, diabetes, congestive heart failure and chronic obstructive pulmonary disease. Even without a recognized medical specialty, the services I provide are as recognized and valued as any other specialty. Not only am I surviving the transformation of our healthcare delivery system, I feel that I am helping to create a future for wound management in a comprehensive care model.
I believe PACE has created the care model that Medicare hopes to build, and I am hopeful that like our PACE architects, Medicare will embrace the vital need for wound management practitioners. It seems likely that the future of our field will be contingent on whether, at the national level, we are able to link quality performance and outcome in chronic wound patients, and properly position our services in the context of holistic disease management, because it’s not just about the hole in the patient but the whole patient.
Traci A. Kimball is a Certified Wound Specialist Physician with InnovAge Greater Colorado PACE-Denver Metro.